Biomedical subjects
Publications and source records attributed to D Fries.
The authors report a case of renal and pancreatic transplantation in a patient with renal failure and type I diabetes. The entire pancreas and duodenum were transplanted, the duodenum was drained into the bladder in order to assay the urinary amylase which is an early criterion of rejection of the exocrine pancreas.
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Ten antegrade endoprostheses were inserted in renal transplant patients. Eight dilatations and 2 intubations were performed. Six stenoses had recurred after 6 months.
123 vascular surgical procedures were performed ex situ in the course of 534 renal transplantations performed between 1982 and 1987. This study demonstrates that the elongation of the renal vein facilitates the transplantation and significantly reduces the risk of arterial stenosis and that arterial repairs, in the case of multiple arteries, constitute a reliable technique. The elongation of the renal vein means that all donor right kidneys must be procured with the infra-renal inferior vena cava. Donor kidneys with multiple arteries without patch graft can be repaired on the table in the great majority of cases.
The factors affecting graft survival in transplant recipients receiving cyclosporin (CsA) are still being debated. Our report is based on an analysis of 202 successive transplantations performed in our institution from May 1984 to December 1986, using low-dose CsA as the basic means of immunosuppression. A total of 142 patients received the triple combination CsA, azathioprine (AZA), and corticosteroids. Sixty patients received a prophylactic combination of CsA, corticosteroids, and antilymphocyte globulins (ALG). From January to December 1986, both regimens were compared in a prospective randomized trial. The factors that affect graft survival were analyzed using the Cox multivariate hazard analysis. The relative risks were calculated for pretransplant baseline risk factors and for outcome-dependent post-transplant risk factors for surviving grafts at 1 month. Transplants performed with a prolonged ischemia time and patients whose graft did not function immediately were statistically at higher risk of graft loss. Adding prophylactic ALG to CsA was associated with better graft survival. Patients who experienced more than 1 rejection crisis and patients whose 1-month CsA dose was lower than or equal to 5 mg/kg per day were also at significantly higher risk of further graft loss. Neither HLA matching, peak panel reactivity, age of the recipient, occurrence of post-transplant renal dysfunction nor 1-month renal function affected the short-term graft outcome.
We report three cases of nodular regenerative hyperplasia of the liver: the clinical onset of hepatic disease occurred between 24 and 30 months after renal transplantation. Nodular regenerative hyperplasia was associated with peliosis hepatitis in two cases, and with veno-occlusive disease in one case. Two patients developed portal hypertension, but are doing well. The third patient developed jaundice and died of septic shock. We discuss the aetiological role of renal transplantation, cytomegalovirus infection, and azathioprine in the development of nodular regenerative hyperplasia of the liver.
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The authors report two cases of aneurysm in renal transplantation: one after removal of the transplant and the other with the transplant in place. In both cases, repair was preceded by excision of the aneurysm and consisted of interposition of an inverted autologous vein graft.
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Cell surface markers of isolated graft-infiltrating cells (GIC) were studied, and functional in vitro assays performed in 8 cases of acute irreversible rejection of human renal allografts. The GIC were mostly activated T cells (OKT11+, OKT3+, Ia+), with predominance of the cytotoxic/suppressor T cell phenotype (OKT8+). A small proportion of B cells and monocytes/macrophages were also present among these GIC. The GIC were able to proliferate with lectin of allogeneic stimulation and were strongly cytotoxic toward specific donor target cells. Within the T cell subset, OKT8+ cells displayed most of the specific cytotoxicity. Despite allograft morphology typical of cellular rejection, anti-HLA complement-dependent antibodies and antibody-dependent cell cytotoxicity were found in the eluted material from rejecting kidneys. The results of our phenotypic and functional testing of unmodified GIC (no enzyme treatment, no additional culture with or without interleukin 2), show that T cells, especially OKT8+ cells, are of paramount importance in the mechanism of this type of acute irreversible rejection of human renal allografts (i.e., to the point of allograft rupture), but other potential effector mechanisms are also present in situ.
Cytomegalovirus (CMV)-specific immune T-cells, present in the circulation of previously infected kidney transplant recipients (anti-CMV serum antibody titer greater than 1/40) can be reactivated to give rise to specific helper and cytotoxic effector cells by co-culturation with fresh autologous blasts coated with CMV antigen in vitro. The reactivated cells are able: 1) to proliferate when stimulated with CMV antigen, 2) to kill the autologous target coated with CMV antigen and not autologous blasts alone when assayed in 51Cr release test. These specific effector cells lie in the E+ T cell subset by removing NK cells with sheep-erythrocytes rosetting. When the reactivated cells are tested against allogeneic CMV coated blasts the level of cytotoxicity is in general related to the extent of HLA-A and B antigen sharing between effector and target cells. The results provide strong evidence that: 1) only previously infected individuals can generate immune T cells against CMV in vitro, 2) there is a correlation between the index of proliferation and cytolysis, 3) there is an HLA restriction of immune T cell cytotoxicity of CMV, 4) monoclonal antibodies directed at several antigenic sites of CMV are able to block cytolysis.
An increased incidence of Kaposi's sarcoma is well known in renal transplant recipients in whom it may represent up to 3 p. 100 of all de novo tumours. This sarcoma has a close relationship with the potential oncogenicity of the cytomegalovirus (CMV) and with chronic immunological deficiency. Anti-CMV immunity is based on the integrity of cytotoxic cellular functions such as those of cytotoxic T lymphocytes (CTL), "natural killers" cells, and K cells which function in the antibody-dependent cell cytotoxicity (ADCC) system. Two cases of Kaposi's sarcoma were observed out of a total of 700 renal transplant recipients; they underwent the following investigations: lymphocyte sub-group counts by murine monoclonal antibodies, lymphocyte proliferation to lectins and allogenic cells, NK activity and generation of specific auxiliary and cytotoxic anti-CMV cells. Both cases of Kaposi's sarcoma were seropositive for CMV and seronegative for LAV. In one case, an abnormal number of peripheral OKT9 + lymphocytes (normally a thymocytic marker) was observed with small numbers of OKT4/OKT8, a reduced proliferative response to mitogens and allogenic cells. All these in vitro changes persisted despite reduction of immunosuppressive therapy and clinical improvement. A clinical and biological cure was only obtained after withdrawal of immunosuppressive therapy and return to haemodialysis. In the second case of Kaposi's sarcoma, the initial biochemical changes were minimal and a clinical cure was obtained by decreasing the immunosuppressive therapy. These two cases illustrate the complex dysregulation of the immune system in Kaposi's sarcoma.
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Fifty-six renal artery stenoses involving transplanted kidneys among a series of 819 renal transplants performed from 1978 to 1986 were treated. Forty-two patients underwent surgery. Surgery was the initial treatment in 38 cases and followed failed or complicated dilatation in four cases. Surgical treatment ensured successful control of hypertension in 85% of cases with a mean time lag of 26 months. Recurrence rate was 12%. Two patients died in the perioperative period. Percutaneous dilatation was performed in 18 renal artery stenoses and ensured control of hypertension in 61% of cases with a mean time lag of 19.6 months and a 33% recurrence rate.