Clinical study of second kidney transplantation

During the period from November 1972 to February 1975, 39 patients received second renal grafts in our institution. The clinical course of the patients was analyzed and compared with 121 patients who received only one graft during the same period. The graft survival either from living related or cadaveric sources was inferior in the second graft group. However, mortality was not increased by re-transplantation. Major differences were noted in the occurrence of hyperacute or accelerated type rejections. There was a high incidence of this type of rejection in the second graft group, especially in the simultaneous retransplant group.     

Heterotopic heart transplant in the cat

Summary A technique for the heterotopic heart transplant into the abdominal cavity of the cat has been developed as an experimental model for studies of the development of sympathetic denervation and of allograft rejection. Under our experimental conditions and in the absence of immunosuppressive treatment the survival rate of the transplant was higher than that reported for dogs. Immediately after the operation the cardiac rate of the transplanted heart was reduced from 153±9 (n=36) to 131±9 beats/min (n=36). After the third postoperative day the rate of the graft increased steadily, reaching 185±8 beats/min (n=15) on the seventh day. The endogenous noradrenaline (NA) content in the right atrium was completely depleted 3 days after the operation (controls 2.07±0.45 g NA/g; transplants 0.09±0.04 g NA/g). In the ventricles a similar degree of depletion was obtained on the seventh postoperative day (controls 1.69±0.25 g NA/g; transplants 0.06±0.02 g NA/g). In vitro studies of strips of left atria revealed supersensitivity to the inotropic effect of (–)-noradrenaline 7 days after the surgical procedures. On the 7th day maximal responses of the atria to (–)-noradrenaline were significantly lower than those of the corresponding controls. There was no increase in sensitivity to (–)-isoprenaline 7 days after the operation. The results obtained demonstrate that the transplanted heart undergoes sympathetic denervation and develops supersensitivity to noradrenaline. The latter appears to be the reason for the tachycardia which develops between the third and the seventh day after the operation.     

Failure of endocardial biopsy from the internal jugular vein due to endocardial scar: A new indication for the femoral venous approach

Following cardiac transplantation, patients undergo serial endomyocardial biopsies to evaluate rejection, usually by the internal jugular approach. A case report and data are presented that demonstrate that this approach becomes less efficient and occasionally impossible in the third year after transplant (53% success rate per biopsy attempt) as compared to the first year after transplant (80%) probably due to the development of endocardial scar in the area sampled by the bioptome. Alternatively, one can change to the femoral venous approach which continues to have a high success rate in the third year after transplant (83%) because a different area of the interventricular septum is sampled when this approach is used.     

Pharmacokinetics of ganciclovir in renal transplant children

Three cytomegalovirus (CMV)-seronegative children received renal transplants from CMV-seropositive donors and developed clinical symptoms of CMV infection between days 20 and 34 post transplantation. Ganciclovir (DHPG) was administered in a 1-h infusion, and the doses and dose intervals were adapted to the degree of renal insufficiency, according to the manufacturer's recommendations for adults. Individual pharmacokinetic parameters of DHPG were determined and were markedly altered. Plasma clearances were 0.4, 1.1 and 2.2 ml/min per kg and were related to individual creatinine clearances (20, 45 and 60 ml/min per 1.73 m²); the corresponding elimination half-lives were 23.7, 9.9 and 3.9 h. In two patients, the doses had to be further reduced in order to maintain plasma levels within the recommended values for peak and trough plasma concentrations. Therefore, monitoring of DHPG appears essential in adjusting dosage for optimal efficacy and minimal toxicity.     

Long-term clinical results of percutaneous transluminal angioplasty in transplant renal artery stenosis.

Twenty-five patients with transplant artery stenosis were identified among 1141 renal graft recipients. Impaired graft function (9 patients), hypertension (4 patients) or both (12 patients) were the indications for arteriography. All were treated by percutaneous angioplasty (PTA). The immediate technical success rate was 88% and actuarial graft survival was 88% and 80% at 2 and 5 years respectively. The long-term success rate on graft function was 67% (median observation time 24 months) and on hypertension 63% (median observation time 23 months). Six patients needed rePTA (8 procedures) and in only one patient was surgical repair performed. No case of graft loss due to PTA was recorded and in only one case did occlusion of a segmental artery lead to impairment of graft function. Minor complications were recorded in four other cases and in no case was surgical intervention necessary. Based on these results we favour PTA as a first-line interventional procedure in transplant renal artery stenosis, and the need for surgical repair has been low.     

Immunosuppression in renal transplantation: Long-term clinical trial of a double versus triple therapy regimen

Summary: Sixty-nine renal allograft recipients were randomized to two immunosuppressive regimens: 35 patients received cyclosporine A and prednisolone (PC) while 34 patients received low dose cyclosporine A, prednisolone and short term azathioprine (PCA). the data of 66 patients (34 in PC and 32 in PCA groups) were analysed. the median follow-up periods were 62 months for the PC group and 60 months for the PCA group. There was no difference in graft survival between the two groups but five patients died in the PC group compared to none in the PCA group (graft survival: 88 vs 90% at 1 year and 82 vs 82% at 5 years, P = not significant at any time point; patient survival: 90 vs 100% at 1 year and 88 vs 100% at 5 years, P = 0.05 at 5 years). There was a trend for patients in the PCA group to develop earlier and more frequent rejections (not significant; P = 0.106 and P = 0.062, respectively). There were also more episodes of acute cyclosporine A nephrotoxicity and cytomegalovirus (CMV) infection in the PC group. the mean serum creatinine at 5 years was significantly higher in the PCA group when compared to the PC group (179.8 ± 76.5 μmol/L vs 154.7 ± 41.0 μmol/L; P =0.05). We found that both therapeutic regimens were effective in preventing renal allograft rejections. However, double therapy was associated with higher patient mortality secondary to infection. Patients on triple therapy, on the other hand, were more prone to develop rejections in the early post-transplant period and were associated with less favourable renal function in the long run.     

Cellulitis Revealing a Cryptococcosis-Related Immune Reconstitution Inflammatory Syndrome in a Renal Allograft Recipient

Immune reconstitution inflammatory syndrome (IRIS) has rarely been described in the course of disseminated cryptococcosis in solid organ transplant recipients. We report here the case of a renal transplant recipient who developed severe cellulitis in the context of Cryptococcus neoformans-associated IRIS while undergoing reduction of his immunosuppressive therapy. IRIS appeared concomitantly with a dramatic increase of blood CD4+ T cells (94-460/mm(3)) and required the administration of a short-term steroid therapy to resolve.     

Percutaneous renal biopsy: comparison of manual and automated puncture techniques with native and transplanted kidneys

The diagnostic usefulness of the biopsy cylinder and biopsy-inducedcomplications were investigated for 458 percutaneous renal biopsies(315 native, 143 transplant kidneys) on 339 patients (averageage, 44.6±18.5 years) under two different biopsy regimes(regime I, manual biopsy technique with Tru-Cut needle, 14 gauge;regime II, automated biopsy technique using a Biopty instrumentand adapted biopsy needle, 18 gauge). In 435 (95%) of the biopsies, kidney tissue with 9.09 ±5.28 glomeruli was obtained (regime I, 93.5%, 9.5±4.9glomeruli; regime II, 96.5%, 8.7 + 5.6 glomeruli; p>0.05).Neither with native nor with transplant kidneys was there anyevident advantage for a particular regime in terms of the diagnosticusefulness of the cylinder. Bleeding complications (perirenalhaemat-omas, bleeding into the renal pelvis, blood clots inthe urinary bladder) were observed in 69 (15.1%) patients (regimeI, 15.6%; regime II, 14.6% P>0.05). Clinically relevant bleedingcomplications were significantly rarer under regime II (9.1%versus 3.5%; P<0.05). Complications were less frequent withtransplant than with native kidneys (12.6% versus 16.2%). Dopplersonography of the biopsied transplant kidneys revealed arteriovenousfistulae in nine cases (6.3%; regime I, 8.0%; regime II, 5.4%). In general, use of an automated biopsy instrument and a thinnerbiopsy needle reduced the number of significant complicationsfollowing percutaneous renal biopsy, while achieving comparablydiagnostic efficacy.     

Doppler and color Doppler imaging in acute transplant failure.

Most renal transplants are lost by rejection. A method is required to identify and discriminate between this and acute tubular necrosis and cyclosporin toxicity. The sonogram of the normal renal transplant is characteristic. Early Doppler studies measuring a rise in vascular impedance in acute rejection showed a high sensitivity and specificity. This appears, at least in part, to have been due to patient selection. We conclude that Doppler studies cannot be used to differentiate between the main parenchymal causes of renal transplant failure, although it can be helpful, with other clinical information, in supporting a diagnosis and in monitoring the effects of treatment.     

Complications associated with central venous catheters used for the collection of peripheral blood progenitor cells to support high-dose chemotherapy and autologous stem cell rescue

 The purpose of this study was to review the incidence and type of complications associated with the insertion and use of central venous catheters for leukapheresis and high-dose chemotherapy with stem cell rescue. One hundred sixty-seven central venous catheters placed either at the transplant center or by various community surgeons were studied for insertion complications, inability to perform leukapheresis and incidence of infection. The overall incidence of hemo- or pneumothorax was 3.6%. Inability to pherese occurred in 13% of catheters placed by outside surgeons and 6.5% of catheters inserted at the transplant institution. Most often, these were due to malposition of the catheter too high in the superior vena cava or in other veins. Deep venous thrombosis was often related to this malposition and occurred in 4.8% of all patients. Pulmonary embolism was not seen in these patients despite the fact the catheters were often left in place during the thrombotic episode. Early or late-onset infections occurred in 6.5% of patients and were most often exit site infections. The incidence of complications of pheresis catheters is high but might be reduced by more attention to proper placement of the catheter closer to the right atrial/superior vena cava junction, and limiting insertion to a cadre of surgeons familiar with leukapheresis requirements.