Renovascular hypertension in children: current concepts in evaluation and treatment

Since 1981, we have evaluated and treated 22 children with renovascular hypertension (RVH). Seventeen patients had stenosis of their native renal arteries, and five had stenosis of the artery in a transplanted kidney. RVH was caused by fibromuscular dysplasia in 13 patients, by trauma in 2 patients, and by arteritis in 2 patients. Among the patients who had transplanted kidneys, three had technical causes for stenosis and two had stenosis due to rejection. The disease was unilateral in 10 patients, bilateral in 5, and present in a solitary kidney in 7, including the five renal transplants. Diagnostic studies that strongly suggested the presence of renovascular disease were an initial diastolic blood pressure greater than 100 mm Hg, an elevated peripheral vein renin activity level, and an abnormal renal scan if the patient's hypertension was being controlled with an angiotensin-converting enzyme inhibitor (ACEI). Only the renal arteriogram was 100% accurate in confirming the presence of RVH. Percutaneous angiographic correction was attempted in 13 patients and resulted in lasting improvement of the hypertension in five (38%). Surgical revascularization was attempted in 17 children, including the 8 with failed angioplasty, with improvement or cure of the hypertension in 15 patients (88%). Combining percutaneous transluminal angioplasty (PTA) and surgical results gave 20 of 22 patients (91%) with cure or improvement of their hypertension. Four of 27 affected kidneys (15%) could not be revascularized and were removed. We conclude from this series of patients that despite improvements in noninvasive studies, renal arteriogram remains the only study that is 100% accurate in evaluating children for RVH.(ABSTRACT TRUNCATED AT 250 WORDS)     

Emergent autotransplantation of a renal allograft

Renal autotransplantation is an acceptable treatment for a variety of renal pathology. Indications for autotransplantation include renal artery diseases, loin pain hematuria syndrome, repair of ureteral pathology, ex vivo tumor resection, and repair of traumatic injury. Long-term results confirm that autotransplantation is a safe and effective procedure. Renal allograft autotransplantation has also been described for repair of vascular disease, and relocation of an allograft. We describe the first case, to our knowledge of an emergent autotransplant of a renal allograft. The patient had undergone a simultaneous kidney-pancreas transplant 7 yr prior. During attempted stenting of a common iliac artery occlusion, the stent migrated, thus jeopardizing the renal allograft. The patient was taken emergently to the operating room for open repair. This included autotransplantation of the entire kidney. The patient recovered to baseline renal function. This article reviews the indications for renal autotransplantation and autotransplantation of a renal allograft. A case of emergent autotransplant of a renal allograft is described.     

Percutaneous transluminal angioplasty for transplant renal artery stenosis in children

Severe hypertension developed secondary to renal artery stenosis in 11 of 229 children who received a renal allograft. Renal artery stenosis was suspected because of de novo development of hypertension or exacerbation of pre-existing hypertension, which was detected 1 to 24 months after transplantation. Selective renal angiography was performed 2 to 74 months after transplantation (mean 13 months). Follow-up was 1 to 8 years (mean 2.5 years). The stenosis involved the anastomosis in 5 patients and was distal to the anastomosis in 6. One graft had an arteriovenous malformation. Seven grafts were suitable for vessel dilation; percutaneous transluminal angioplasty was partially successful in 4 cases in which the stenosis occurred at the anastomosis. The remaining patients were treated with medical therapy alone and the grafts were not lost. Our findings suggest that strictures distal to the anastomosis rarely are amenable to percutaneous transluminal angioplasty and should be treated medically whenever possible. Strictures at the anastomosis respond to vessel dilation but antihypertensive medication also often is required. An operation should be reserved for patients who do not respond to these measures.     

Campath IH allows low-dose cyclosporine monotherapy in 31 cadaveric renal allograft recipients

BACKGROUND: Campath 1H is a depleting, humanized anti-CD52 monoclonal antibody that has now been used in 31 renal allograft recipients. The results have been very encouraging and are presented herein. METHODS: Campath 1H was administered, intravenously, in a dose of 20 mg, on day 0 and day 1 after renal transplant. Low-dose cyclosporine (Neoral) was then initiated at 72 hr after transplant. These patients were maintained on low-dose monotherapy with cyclosporine. RESULTS: At present, the mean follow-up is 21 months (range: 15-28 months). All but one patient are alive and 29 have intact functioning grafts. There have been six separate episodes of steroid-responsive rejection. One patient has had a recurrence of her original disease. Two patients have suffered from opportunistic infections, which responded to therapy. One patient has died secondary to ischemic cardiac failure. CONCLUSIONS: Campath 1H has resulted in acceptable outcomes in this group of renal allograft recipients. This novel therapy is of equal efficacy compared to conventional triple therapy, but allows the patient to be steroid-free and to be maintained on very-low-dose immunosuppressive monotherapy.     

Contrast-induced nephrotoxicity in renal allograft recipients

BACKGROUND: Intravenous administration of radiographic contrast agents is an important cause of acute renal failure, accounting for one third of the cases of hospital-acquired acute renal failure in patients with native kidneys. The safety of intravenous contrast has not been studied in renal allograft recipients since the availability of cyclosporine as a maintenance immunosuppressive therapy. As patients with renal transplantation may be at a higher risk of contrast-induced nephrotoxicity (CIN) due to concomitant use of cyclosporine and higher prevalence of diabetes and renal insufficiency, we retrospectively studied development of CIN in these patients. PATIENTS AND METHODS: We identified 44 patients (1988 1997) with functioning renal allograft who underwent different intravenous or intraarterial contrast studies (ICS). Pre- and post-ICS renal function tests were done in 35 of these patients. The following were the various ICS done in these patients: coronary angiogram (6), CT scan with intravenous contrast ( 11), angiogram for evaluation of peripheral vascular disease (11), allograft angiogram with angioplasty (5), pulmonary angiogram (1) and intravenous pyelogram (1). The mean age of the patients was 42 +/- 2.1 years and the mean serum creatinine was 2.3 +/- 0.25 mg/dl (mean +/- SEM). Fourty percent of patients (14 of 35) had diabetes, and 25.7% (9 of 35) had chronic rejection. Ninety four percent (33 of 35) of the patients were taking cyclosporine at the time of ICS. RESULTS: Nine patients had > or = 25% increase in serum creatinine from baseline after ICS. Two of these patients were excluded from the analysis as renal functions in these patients had deteriorated prior to ICS and renal failure was attributed to sepsis. Of the remaining 7 patients, 5 had diabetes and 2 had chronic rejection. Only 4 of these 7 patients with CIN received prophylaxis (I/V hydration) prior to ICS. The baseline serum creatinines were not different in patients who had no change in renal function to those who developed CIN (1.97 +/- 0.20 vs 1.54 +/- 0.17 mg/dl, p = 1.5, mean +/- SEM). More than 50% increase in baseline serum creatinine was seen in only 3 of these 7 patients, 2 of these patients had diabetes and third had chronic rejection and congestive heart failure. None of these patients received prophylaxis for CIN. Dialysis was not required in any patient. Three patients also had a > 25% decrease in baseline serum creatinine after ICS, and all of them had allograft angiography with angioplasty for renal artery stenosis. CONCLUSION: In our retrospective study, the incidence of CIN in renal allograft recipients applying a broader classification of > or = 25% increase in baseline serum creatinine was 21.2% (7 of 33 patients). The incidence of CIN was lower 15.3% (4 of 26) in patients who received intravenous hydration compared to 42.8% (3 of 7) in patients who received no prophylaxis prior to ICS.     

Cardiac surgery after renal transplantation

Renal transplantation remains a mainstay of therapy for end-stage renal disease. Cardiac disease has a high prevalence in this patient population. This study reviews the factors and outcomes associated with cardiac surgery in renal transplant recipients. We performed a retrospective review of all patients at our institution with a functioning renal allograft at the time of their cardiac surgical procedure. Between June 1971 and April 2000, 2343 patients underwent renal transplantation at Vanderbilt University Medical Center. Twenty-six patients with a functioning renal allograft subsequently underwent a cardiac procedure requiring cardiopulmonary bypass. There were 11 women and 15 men. Twenty-four patients underwent coronary bypass, one had a double valve replacement, and one had a combined coronary bypass/valve replacement. The interval from renal transplant to heart surgery ranged between 0.6 and 227 months (mean 79.1). Operative mortality was zero but there were two hospital deaths: one due to multisystem organ failure and one due to pulmonary embolism. Six additional patients died late with only one due to heart disease. Four patients required perioperative dialysis, and one of these went on to require permanent dialysis. Two additional patients returned to dialysis late postoperatively. The requirement for acute perioperative dialysis was predicted by preoperative creatinine, hematocrit, and intraoperative urine output. The overall survival is 69 per cent (18 of 26) with a median follow-up of 38 months. The majority of long-term survivors have minimal cardiac symptoms. Standard cardiac surgery procedures can be performed with relative safety in patients with functioning renal allografts. The incidence of perioperative and late development of renal failure requiring dialysis is low. The long-term survival and symptomatic improvement achieved are favorable and warrant continued performance of cardiac surgery in patients with functioning renal allografts.     

Autotransplantation for renovascular hypertension with complete renal artery occlusion.

We report a personal series of 13 autotransplantation procedures in 12 patients who suffered from severe renovascular hypertension. In all of these cases preoperative investigation demonstrated a viable kidney, despite complete occlusion of the affected renal artery. One-half the patients had stenosis of a milder degree affecting the contralateral kidney. In eight of these patients the operation was considered successful. One patient died due to postoperative superior mesenteric artery thrombosis and two had infarction of the transplanted kidney. A fourth patient lost the autotransplant because of postoperative haemorrhage. It is suggested that if medical treatment fails then autotransplantation should be considered in place of nephrectomy for cases of renovascular hypertension with complete occlusion of the renal artery.     

Single-dose captopril test and captopril renal scintigraphy in the evaluation of renovascular hypertension]

The effectiveness of single-dose captopril test (CP-T) and captopril renal scintigraphy with 99mTc-DTPA (CP-RG) in the diagnosis of renovascular hypertension (RVH) was evaluated in 27 patients with (Group I, 16 patients) or without (Group II, 11 patients) renal vascular disease. Group I consisted of RVH in 8 patients (bilateral in 3, unilateral in 5), arteriovenous malformation in 3, renal artery aneurysm in 4, including 2 with essential hypertension, and asymptomatic renal artery stenosis in 1. Group II consisted of 6 hypertensive patients (2 with essential hypertension and 4 with renal hypertension) and 5 normotensive patients. Sensitivity of CP-T and CP-RG in the diagnosis of RVH was 29% (2/7) and 86% (6/7), respectively, indicating the latter was more sensitive than the former. In 3 patients with bilateral RVH, positive response in CP-RG was observed only in the unilateral kidney. Specificity of CP-T and CP-RG was 86% (6/7) and 100% (5/5), respectively in Group I, 100% (8/8) and 83% (5/6), respectively in 16 hypertensive patients. CP-T and CP-RG before and after the treatment of RVH were evaluated in 4 patients. The change of positive response in CP-T and CP-RG into negative after percutaneous transluminal renal angioplasty (PTA) or surgery were found in 3, all followed by a fall in blood pressure, which was not observed in the other patient with positive response after PTA.(ABSTRACT TRUNCATED AT 250 WORDS)     

移植肾动脉瘤五例报告

目的 探讨移植肾动脉瘤(RAA)的病因、诊断及治疗. 方法 1998年8月至2004年12月共行同种异体肾移植手术1251例,发生RAA 5例(0.4%).5例均为男性,平均年龄43岁,移植肾血管吻合方式均为移植肾动脉一髂内动脉端端吻合.患者主要临床表现为进行性肾功能减退,突发少尿或无尿,顽固性高血压及肾区疼痛,均经彩色多普勒超声、数字减影血管造影检查确诊为动脉瘤,动脉瘤大小1.8 cm×2.0 cm×2.0 cm～4.0 cm×4.0 cm×5.0 cm. 结果 移植肾动脉吻合口动脉瘤2例,1例发现动脉瘤后1个月内移植肾功能丧失,行移植肾切除术,术后规律透析治疗,随访1年后行二次肾移植;1例移植肾失功后1周内行对侧髂窝二次肾移植手术,保留原移植肾,术后随访2年肾功能正常.RAA合并近端移植肾动脉狭窄2例,1例行吻合口球囊扩张并放置支架后,以弹簧螺圈栓塞动脉瘤,术后随访1年肾功能稳定;1例行移植肾切除、二次.肾移植术,术后随访3年肾功能正常.吻合口髂内动脉侧粥样硬化斑块导致髂内动脉狭窄、移植肾动脉侧动脉瘤1例,行移植肾切除术,术后2 d因脑干栓塞死亡. 结论 移植肾动脉-髂内动脉端端吻合易诱发血管并发症,RAA治疗应谨慎采用开放手术切除,可选择近期行二次肾移植和血管内介入治疗.     

ACE inhibition in the treatment of children after renal transplantation

Currently, there are no data available on long-term effects of angiotensin-converting enzyme inhibitors (ACE-I) on graft function in children after renal transplantation. We therefore analyzed all children who were transplanted at our institution between 1989 and 1998 and followed for at least 2 years. Those treated with ACE-I, mainly because of failure of other antihypertensive medications, were compared to those without ACE-I. The ACE-I-treated children (n=19) showed significantly better blood pressure control during the 1st year of follow-up (p<0.05). In children with chronic allograft dysfunction (n=8), treatment with ACE-I stabilized graft function, with improvement in creatinine clearance in 50% (p<0.01). Serum potassium and hemoglobin levels remained stable. One patient discontinued ACE-I because of renal artery stenosis. Taken together, ACE-I were effective and safe in the treatment of hypertension in children following renal transplantation. Children with chronic allograft dysfunction experienced a stabilizing effect on graft function.     

Postransplant lymphoproliferative disorder localized near the allograft in renal transplantation

BACKGROUND: Posttransplant lymphoproliferative disorder (PTLD), a complication of immunosuppression, develops in approximately 1% of renal allograft recipients. Typically, PTLD is a proliferation of B-cells associated with Epstein-Barr virus (EBV) infection; it is said to be most often a systemic disease. Involvement occasionally is localized near the allograft. METHODS: This is a retrospective analysis of all cases of PTLD in recipients of 1474 renal transplants performed at University of Alabama at Birmingham between 1993 and 1997. RESULTS: Of 14 patients developing PTLD, 10 had disease localized near the allograft. The mean interval from transplantation to diagnosis was 221 +/- 70 days. All patients presented with renal dysfunction; an ultrasound examination revealed a hilar mass, with hydronephrosis in five and stenosis of renal vessels in eight. No patient had lymphadenopathy, according to computerized tomographic or magnetic resonance imaging findings. After reduction of immunosuppressive therapy, seven required a nephrectomy because of rejection, progressive dysfunction, or mass enlargement. Tissue recovered in four patients was consistent with PTLD; the tumors in the remaining three patients were unresectable and regressed. One patient died 1 month after a nephrectomy, and another died 4 years after surgery; neither had evidence of PTLD when they died. Three patients retain functional grafts without clinical or radiographical evidence of progression. All patients with disseminated disease died. CONCLUSIONS: In a large cohort of renal allograft recipients, PTLD affected 1%. Disease localized near the allograft was the most common variant. For most patients with localized disease, the outcome was graft loss, and the mortality was low. Localized PTLD should be considered in the differential diagnosis of allograft dysfunction in the 1st posttransplant year.     

Surgical treatment of fibromuscular dysplasia of renal arteries in adults

The authors have analyzed an experience with treatment of 16 patients. All the patients had renovascular hypertension (RVH) and 3 of them had renal dysfunction. Revascularization of the kidneys (RK) was fulfilled in 11 patients by shunting (9) or prosthesis (2) of the renal arteries. In 7 patients percutaneous endovascular angioplasty (PEA) was used. There were neither complications nor lethal outcomes. Arterial pressure normalized in 7 patients and in 9 RVH was better. In the long-term period (at the average within 21 months) 14 patients were followed-up. In 3 patients having perimedial and intimal fibroplasty of RA after PEA restenoses were diagnosed. They had repeated RK. Renal function became better in 1 patient, in 2 patients there was no substantial dynamics. All shunts were passable. The analysis of the data has shown that liquidation of RVH in patients with FMD of RA has inverse dependence on its duration, and decision on the method of RK depends on the type of RA, experience of the specialists, the patients desire included.     

Renovascular hypertension in children.

OBJECTIVE: To study the etiology, clinical spectrum. image findings, management and outcome of children with renovascular hypertension (RVH). MATERIAL AND METHODS: Twenty children (aged 5 days to 15 years) were studied and treated for RVH during 1977-1998. In 14 cases hypertension was found during a routine examination. Six cases had heart failure and/or hypertensive encephalopathy. Diagnosis was made with aortography. Post-captopril renography and Doppler ultrasonography were obtained in 8 patients and spiral computed tomography angiography in 2. Treatment consisted of surgery (8 patients), percutaneous transluminal angioplasty (PTA) (5) or antihypertensive drugs only (8). RESULTS: Initial blood pressure was 62 +/- 31 mmHg > 95th percentile for systolic and 44 +/- 22 mmHg for diastolic blood pressure. Twelve children had unilateral and 8 had bilateral arterial stenosis. In 3 cases lesions were intrarenal. RVH was due to fibromuscular dysplasia (7 patients) and associated to middle aortic syndrome (5). neurofibromatosis (3), William's syndrome (2). Takayasu's arteritis (1) and pheochromocytoma (1). Treatment of choice was decided depending on the size of the child and location and severity of the stenosis. At the end of the follow-up (78 +/- 49 months), 9 patients are normotensive without medication and 7 are normotensive with drugs. Three patients have died, 2 for unrelated causes and I for cardiac failure; 1 child was lost to the follow-up. CONCLUSIONS: Although symptoms are relatively uncommon. renovascular disease is a frequent cause of severe hypertension in childhood. Non-invasive diagnostic techniques appear useful as screening methods. Treatment by surgery or PTA is successful if patients are carefully selected.     

The impact of renal failure on survival following cardiac transplantation

OBJECTIVE: Renal failure after cardiac transplantation is a common and serious complication. In this study we investigated the incidence and effects of renal failure on survival among patients who underwent cardiac transplantation. PATIENTS: Eight patients underwent cardiac and one patient combined cardiac and renal transplantation. The mean age of the patients was 33 +/- 11.6 years (range, 17 to 51). On preoperative echocardiographic evaluation, the mean ejection fraction was calculated as 19 +/- 3.11% (range, 16% to 24%). One patient had compensated renal failure and one patient, dialysis-dependent renal failure. Hemofiltration was routinely used during the operations. Corticosteroids, cyclosporine, and mycophenolate mofetil were used for immunosuppression. Early renal replacement therapy was performed in patients with acute renal failure. RESULTS: The incidence of acute renal failure was 55.5% (5 patients). In the early postoperative and follow-up periods, the mean ejection fraction was 55 +/- 9.9% and 57 +/- 4.5%, respectively. The mean follow-up period was 21.3 +/- 8.8 (range, 6 to 33) months. In the early initiation period, the mean peak value of cyclosporine blood level was 479 +/- 201.8 ng/mL during the first month, 250 +/- 95.3 and after the third month, 195 +/- 43.7 ng/mL. The mean creatinine level at last follow-up was 1.27 +/- 0.4. One patient experienced a grade III-A rejection episode. One patient died due to coronary artery occlusive disease at 31 months after transplantation. COMMENT: In our study we have observed that renal failure had no negative effect on patient survival. This can be explained by improved cardiac performance, keeping cyclosporine levels low finding and utilizing early renal replacement treatment.     

Mortality risk in children after renal allograft failure: a NAPRTCS study

Studies have shown that adult dialysis patients with a failed renal allograft face a greater risk of mortality on dialysis compared with transplant-naïve patients. The outcome of children returning to dialysis after allograft failure has not been previously studied. Using the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry, we studied patients aged 2-21 years who initiated dialysis from 1 January 1992 to 31 December 2007. Of a total of 5,006 patients, 1,031 patients had a prior history of allograft failure and 3,975 did not (transplant-naïve). Demographic characteristics, including age at dialysis initiation, race, dialysis modality, primary renal disease, era of dialysis initiation, height Z score, and weight Z score were significantly different between the groups (p?p?=?0.08). After covariate adjustment, allograft failure was not a significant factor contributing to increased mortality risk on dialysis (HR 0.98, CI 0.64–1.50, p?=?0.94) based on Cox regression analysis. Children with failed allografts who return to dialysis are not at greater risk of mortality than their transplant-naïve dialysis counterparts.     

Simultaneous heart and kidney transplantation for combined cardiac and renal failure

Simultaneous heart and kidney transplantation (SHKT) is feasible for combined cardiac and renal failure. Herein we reviewed our 10-year experience in SHKT. Six patients underwent SHKT from June 1995 to December 2004. Their ages ranged from 13 to 63 years old with a mean of 45.5 +/- 15.8 years. They were all men except one girl, who was the youngest (aged 13) who suffered from dilated cardiomyopathy with congestive heart failure and chronic renal failure due to systemic lupus erythematosus. Because of aggravating heart failure, she changed from hemodialysis to peritoneal dialysis. Because of intractable heart failure, she underwent SHKT from a 24-year-old female donor. All received hemodialysis before SHKT. The indications for heart transplantation included dilated cardiomyopathy (n = 3), ischemic cardiomyopathy (n = 1), cardiac allograft vasculopathy (n = 1), and cardiac allograft failure (n = 1). The immunosuppressive protocol and rejection surveillance were these employed for heart transplantation. No operative mortality was noted in this study. The 1-year and 5-year survival rates were the same, 83%. The 10-year survival rate was 55%. No cardiac or renal allograft rejection was noted. No renal allograft loss was noted. There were two late mortalities: the one, who underwent redo heart transplantation for coronary artery vasculopathy died of cardiac allograft failure 1 year after SHKT. The other patient died of massive ischemic necrosis of the intestine at 6 years after SHKT. Our experience showed that SHKT had good short- and long-term results without increasing immunosuppressive doses. End-stage failure of either the heart or the kidney did not preclude heart plus kidney transplantation.     

Incidence and outcome of transplant renal artery stenosis: single center experience

Since the incidence of transplant renal artery stenosis (TRAS) in renal allografts varies from 1% to 23%, we sought to examine its incidence, to analyze treatment options, and to ascertain its outcomes. Retrospective analysis of 793 kidney allograft recipients transplanted between 1996 and 2004 revealed an incidence of 0.9% (n = 7). Time from kidney transplantation to the first symptoms varied from 1 week to 3 years (median, 4 months). Three patients experiences refractory hypertension and six patients developed allograft dysfunction. Screening color Doppler ultrasonography showed hemodynamic changes in six patients with the definitive diagnosis confirmed by angiography in all patients. One patient with an anastomotic stenosis was treated with a surgical operation and six patients, percutaneous transluminal angioplasty (PTA), with stenting in three cases. Both surgical as well as PTA treatment were successful in all but one patient, who underwent PTA alone, developed chronic renal insufficiency necessitating hemodialysis and finally lost his allograft. In the other patients all symptoms resolved after treatment and the patients are doing well with functioning allografts. Although TRAS was an uncommon complication, if recognized promptly it could be treated by surgery or PTA with a high success rate.     

Cardiac operations in patients with functioning renal allografts

The Transplant Service at the University of Minnesota Hospitals has performed over 2,000 kidney transplants. Fourteen of these patients have developed cardiac conditions necessitating surgical intervention at intervals of 9 to 144 months (mean 67 months) following their transplantation. These individuals had a mean age of 42 years, and five (36%) were diabetic. All patients had functioning renal allografts with preoperative serum creatinine levels ranging from 1.0 to 1.8 mg/100 ml (mean 1.4 mg/100 ml). Ten patients underwent aorta-coronary saphenous vein bypass grafting. One patient underwent bypass grafting and concomitant left ventricular aneurysmectomy. Native valvular endocarditis developed in two patients. One had tricuspid valve debridement for fungal endocarditis and the other had aortic valve replacement for bacterial endocarditis. The final patient had calcific aortic stenosis and coronary artery disease necessitating aortic valve replacement and coronary bypass. Two patients (14%) died perioperatively. One was a young woman with juvenile-onset diabetes and preinfarction angina who died suddenly several days after the operation; at autopsy, she was found to have an occluded graft to the right coronary artery and extensive infarction. The other was a 54-year-old woman with calcific aortic stenosis, coronary artery disease, and unstable angina who died perioperatively of uncontrollable arrhythmias. Autopsy suggested that she may have had an unsuspected infarction 1 to 2 days before the operation. The remaining 12 patients had uneventful postoperative courses and returned to Class I functional status from a cardiac standpoint. There has been one late death (7%), 45 months after successful coronary artery bypass grafting, as a result of complications attendant to a perforated gastric ulcer. The remaining 11 patients are alive and well at intervals of 8 to 93 months (mean 31 months) after operation. Postoperative serum creatinine levels at hospital discharge averaged 1.6 mg/100 ml, not significantly changed from preoperative levels. Cardiac operations can be performed safely in patients with functioning renal allografts. Patient survival is acceptable and preservation of renal function has been uniformly successful in surviving patients.     

Patient and technique survival on peritoneal dialysis in patients with failed renal allograft: a case-control study

Failed renal allograft is becoming one of the most frequent causes of dialysis initiation in countries with developed transplant programs. The majority of patients initiate hemodialysis (HD) as their next renal replacement modality and concerns about the success of peritoneal dialysis (PD) in this patient population has been expressed. We evaluated patient and technique outcome in a cohort of 494 patients in the United States who initiated PD after a failed renal allograft in the years 2000-2003, and compared the outcomes to those of two case-matched groups: patients new to dialysis or patients transferred from HD who started PD during the same period. Patients starting PD after a failed allograft had patient survival and technique survival similar to case-matched controls. Transplantation was lower in patients with failed allograft than controls. The high success of PD in patients with failed allograft suggests that it is beneficial to utilize this modality more frequently in this patient group than current practice.     

Long-term outcome of renal transplantation in autosomal dominant polycystic kidney disease

This study was performed to determine the long-term outcome of renal transplantation in 54 patients with end-stage renal failure secondary to autosomal dominant polycystic kidney disease (ADPKD) and in 107 patients with renal diseases other than ADPKD or diabetes mellitus matched by gender, age, year of transplantation, and source of the allograft. The overall patient survival and patient survival with a functioning first renal allograft were similar in both groups. Infection and cardiovascular accidents were the leading causes of early and late death in both groups. No cause of death was greatly overrepresented in the ADPKD group. Serious complications from extrarenal manifestations of ADPKD following renal transplantation included a ruptured intracranial aneurysm in one patient, a dissection of the ascending thoracic aorta in one patient, and infected hepatic cysts in two patients. Neoplasia (other than skin or cervical) occurred in four ADPKD patients and in one control patient and included one lymphoma in each group. Two ADPKD and one control patient had monoclonal gammopathies of undetermined significance. No complications related to the retention of native kidneys were detected in 12 ADPKD patients with a mean follow-up of 3 years. Cysts were observed in the renal allografts of some patients in both groups at autopsy and in a prospective computed tomography (CT) study of the allograft. However, we failed to detect a significant difference in the occurrence and number of the cysts between ADPKD and control patients.