Biomedical subjects
Publications and source records attributed to S N Chatterjee.
A case is reported in which a cadaveric renal allograft was placed successfully in a patient with a bilateral aortofemoral prosthesis for extensive vascular disease. Convalescence was uneventful and the subsequent clinical course seems to justify fully this operative approach.
To determine the incidence and symptomatology of cytomegalovirus (CMV) infection in renal transplant recipients, we followed 40 patients prospectively for 5 to 24 months after operation. As judged by the serological change and virus isolation from blood and/or urine, the infection rate for the entire group was 82% (33 of 40 patients). Two types of infection were recognized: primary infection that occurred in 3 patients, and reactivation infection that occurred in 30 patients. Twenty-one patients were asymptomatic and 12 were mildly symptomatic. Four had mild hepatic dysfunction; two had the CMV mononucleosis syndrome associated with mild to moderate deterioration of renal function. Two patients had hyperglycemia. One patient who reached a CMV antibody titer of 1:32,768 was totally asymptomatic other than fever of short duration. CMV-induced pneumonitis or retinitis was not noted, and there was no mortality from CMV infection in our patients. Factors which may be associated with the absence of severe manifestations of active CMV infection in these patients are discussed.
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Thirty-five renal allograft recipients were studied concerning the relationship between cytomegalovirus (CMV), herpes simplex virus (HSV), and opportunistic bacterial and fungal infections. The incidence of opportunistic infections was determined for patients whose tests prior to transplantation were seronegative in complement fixation and indirect hemagglutination assays of CMV antibody and for those patients whose tests were seropositive. Among the six seronegative patients with seronegative tests, four (66%) experienced active CMV infection within two months, and four died of Candida or Aspergillus infection within six months after transplantation. Among the 22 patients with seropositive tests, only one (4%) had a fungal infection and it was nonfatal (P less than .05). The increased morbidity and mortality due to fungal and bacterial infections in transplant recipients with seronegative CMV tests appears, therefore, to be related to primary CMV infection rather than to generalized immunodeficiency.
A black male with known sickle cell trait (hemoglobin AS) received two cadaveric renal transplants in succession. After excellent initial graft function he had what appeared clinically to be an acute rejection episode which could not be reversed by immunosuppressive therapy on either occasion. The histopathology of the removed allografts did not reveal a picture of acute rejection, but instead revealed extensive intravascular sickling of the erythrocytes. This is important especially for the transplant centers in the United States which may have a significant number of the black population among the renal allograft recipients.
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The current overall reported incidence of major urologic complications following renal transplantation is 5 per cent. The presence of such a complication increases the likelihood of patient mortality by a factor of three. Standard utilization of postoperative radionuclide scanning is very useful in early diagnosis. Vesical fistulas generally result from improper bladder closure. The incidence of bladder complications increases with secondary and tertiary grafts. Ureteral complications result when the blood supply of the ureter is impaired. These include fistula formation, necrosis, and obstruction. Immediate surgical correction is indicated in almost all serious urologic complications following transplantation; otherwise there is marked increase in morbidity and mortality. Complications appearing early in the postoperative period carry a poor prognosis for both graft and recipient survival. The presence of urinary tract infection early in the postoperative period also correlates negatively with graft survival. The presence of multiple renal arteries in the donor has been associated with an increased rate of urologic complications. Ureteral fistulas can be avoided by meticulous dissection of the donor at the time or organ harvesting. Great care must be taken to preserve the arterial and venous blood supply to the ureter by avoiding any dissection into the renal hilum. Aberrant renal arteries must be preserved or repaired if damaged. Ureteroneocystostomy is the preferred method for re-establishing urinary tract continuity following transplantation. The immediate surgical correction of urologic complications is mandatory, and the techniques involved are highly specialized and must be individualized with each patient.
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Cytomegalovirus (CMV) retinitis is reported in 2 patients who received immunosuppressive medication after cadaveric renal transplantation. The clinical features of this disease as well as the differential diagnosis are presented. Reduction in the amount of immunosuppressive drugs given postoperatively is suggested as the definitive treatment of this disease. Available specific antiviral chemotherapeutic agents were ineffective against CMV retinitis. This finding may be modified at a later date, with the introduction and use of new effective and safe antiviral drugs.
Opportunistic pulmonary infections often appear in patients requiring immunosuppressive therapy following renal transplantation. Fungal protozoal, viral and bacterial infections demand an immediate definitive diagnosis, since the outcome is related to the rapidity in establishing a diagnosis and the institution of appropriate therapy. Of 200 consecutive renal transplants during a seven year period, severe pulmonary infections developed in 21 patients. In 17 patients, a specific infectious agent was identified, using the flexible fiberoptic bronchoscope. Pathogenic specimens were obtained by bronchial washing, brushing or transbronchoscopic biopsy of the lung through the inner channel of the flexible bronchoscope. Bronchoscopy for localized lesions of the lung was aided by fluoroscopic guidance; for diffuse lesions, a roentgenogram of the chest was used to obtain bronchoscopic specimens from areas of maximum infiltration. Specimens were immediately dispatched and processed by the pathology laboratory. Except for one patient, all the others with fungal, protozoal and viral infections survived with functioning kidneys. Three deaths resulted from bacterial infections. Antemortem diagnoses were confirmed in all four patients who died.