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PubMed2003

Posttransplant lymphoproliferative disease: treatment and outcome in renal transplant recipients.

UNLABELLED: Posttransplant lymphoproliferative disorders (PTLD) are a heterogeneous group of lymphoid diseases that occur after solid organ and bone marrow transplantation. We performed a retrospective study to assess the incidence, response to treatment, and patient and graft survival after PTLD. PATIENTS: Between January 1980 and December 2002, 1.96% (n=10) of 509 renal transplant recipients developed PTLD. Seventy percent were men. Mean age was 40 years (range 21-65). They were classified into four groups based upon the type of PTLD: group I, early lesion (n=1); group II, polymorphic PTLD (n=1); group III, monomorphic PTLD (n=7) including five non-Hodgkin lymphoma [NHL] and two Burkitt (BL); and group IV, Hodgkin lymphoma (HL) (n=1). The mean time from transplantation to diagnosis was 77 months (range 4-138). Although only 20% of cases were early presentation, Epstein-Barr virus (EBV) was found in the tumor cells of seven cases. Treatment was individualized according to PTLD type: for group I, immunosuppression reduction (IR); group II, IR plus acyclovir; group III, withdrawal or IR plus chemotherapy and/or surgery in all but one patient who was also treated with anti-CD20 monoclonal antibody and radiotherapy. Interferon was also used in one patient. For group IV, treatment was IR plus radiotherapy. RESULTS: A complete response was achieved in nine cases (90%) with one recurrence. Three patients returned to dialysis. One patient with BL died. CONCLUSIONS: The incidence of PTLD in our center was 1.96%. Patient survival after PTLD was 90%, with 60% maintaining allograft function. Individualized treatment according to extension, histology, and location is mandatory to obtain a high survival rate.

Adult↗

PubMed1994

Renal transplantation in patients with renal cell carcinoma and von Hippel-Lindau disease.

This study reviewed the management and outcome of patients with von Hippel-Lindau disease (VHLD) who underwent renal transplantation after being rendered anephric to treat multifocal bilateral renal cell carcinoma (RCC). Five patients with bilateral RCC and VHLD underwent renal transplantation at our hospital. Initial treatment of RCC consisted of bilateral nephrectomy in 2 patients and unilateral nephron-sparing surgery with contralateral nephrectomy in 3 patients. All of the latter 3 patients experienced isolated tumor recurrence in the renal remnant at 48, 64, and 66 months postoperatively; this was managed by complete excision of the renal remnant. Renal transplantation was performed 11 to 24 months after initiation of dialysis. Postoperatively, all of the allografts functioned well with no further requirement for dialysis. Currently, 4 patients are alive at a mean post-transplant follow-up interval of 26 months (range, 7 to 66 months) with excellent graft function and no evidence of malignancy. One patient died 17 months following transplantation due to metastatic disease. Renal transplantation can provide satisfactory replacement therapy for patients with end-stage renal disease with VHLD and treated RCC.

Adult↗

PubMed1997

Laparoscopy in renal transplant patients.

OBJECTIVES: To evaluate the use of laparoscopic techniques in patients with a renal transplant. METHODS: Since 1992, 358 patients have undergone urologic laparoscopy at our hospital. Among these, 37 procedures (10.4%) were performed in patients with a renal transplant: 14 bilateral nephrectomies for severe drug-resistant hypertension, 9 marsupializations of symptomatic lymphoceles, 6 renal allograft biopsies in patients with clotting abnormalities, 6 unilateral nephrectomies, and 2 nephroureterectomies for recurrent episodes of pyelonephritis and symptomatic vesicoureteral reflux, respectively. RESULTS: Five complications (14%) and three conversions (8%) occurred. Patients who underwent successful laparoscopic operations began mobilization and oral intake on the day after the operation. The hospital stay ranged from 1 to 6 days. In the nephrectomy groups, perioperative urine outputs remained stable and post-operative urine outputs were increased as compared with those in the perioperative period (P < 0.05). Post-operatively, serum creatinine remained stable or improved in patients who underwent nephrectomy or marsupialization of lymphocele. CONCLUSIONS: Our results indicate that laparoscopic techniques are safe and effective in the treatment of patients with a renal transplant. Renal allograft function apparently is not affected by laparoscopic procedures.

Adult↗

PubMed2001

Laparoscopic live donor nephrectomy.

Laparoscopic donor nephrectomy offers numerous advantages when compared with the traditional open approach. For the donor, it has resulted in a shorter hospital stay, fewer postoperative analgesic requirements, earlier return to activities of daily living and employment, and decreased financial loss owing to absence from the workforce. For the recipient, the procedure does not adversely impact on allograft function, graft survival, or patient survival.

Humans↗

PubMed2001

Laparoscopic surgery in renal transplant recipients.

An exponential increase has occurred in the use of laparoscopic surgery in patients who have undergone prior renal transplantation. The main indications are the treatment of symptomatic pelvic lymphoceles and native kidney nephrectomy for various reasons. Most reports have shown laparoscopy to be equally effective and less morbid than conventional open surgery. In addition to conferring the benefits of a minimally invasive approach, laparoscopy potentially offers three advantages specific to this immunosuppressed population of patients. First, it avoids the potential wound-related problems inherent in open surgery. Second, by reducing hospitalization, it reduces the risk for nosocomial infections. Third, by allowing an earlier resumption of oral intake, it enables the continuation of oral immunosuppression. Proper perioperative management of fluid and electrolyte balance is critical in this group of patients. Despite concerns, there is no evidence showing that laparoscopy adversely affects allograft function.

Humans↗

PubMed2001

Long-term outcome of ABO-incompatible renal transplantation.

Based on the long-term experience with ABO-incompatible kidney transplantation, the following can be concluded: 1. Renal transplantation across ABO incompatibility is an acceptable treatment for patients with end-stage renal failure. [table: see text] 2. Long-term patient and graft survival in ABO-incompatible kidney transplantation is influenced primarily by acute rejection episodes occurring within 1 year. 3. Despite the removal of anti-ABO natural antibodies before transplantation, hyperacute rejection crises may occur in some cases. 4. Humoral rejection is the most prominent type of rejection in ABO-incompatible renal transplantation. Even though most of this rejection is controllable with anti-rejection therapy, the prognosis for a graft that undergoes humoral rejection is significantly poor. 5. The maximum IgG titers of anti-A/B antibody before transplantation may have a harmful effect on graft acceptance in ABO-incompatible kidney transplantation. 6. Renal transplantation across ABO incompatibility is principally the most significant risk factor to affect long-term allograft function in ABO-incompatible living kidney transplantation.

ABO Blood-Group System↗

PubMed2000

Renal transplantation: laparoscopic live donor nephrectomy.

Laparoscopic nephrectomy is now performed at many centers worldwide. This technique for organ harvesting offers less postoperative pain, quicker convalescence, and an optimal cosmetic result when compared with the traditional open approach. With experience, the laparoscopic technique is accomplished without compromise to donor safety or allograft function, and complications are comparable with the rates in open historic series. Longer operative times and the need for disposable equipment result in greater hospital costs; however, the quicker convalescence permits patients to resume activity sooner, allowing marked cost savings for patients and employers. The laparoscopic technique is associated with a steep learning curve. Launching a successful laparoscopic living donor program requires a dedicated coordinated effort involving physicians, nurses, and hospital administration. The ultimate impact of this technique on the willingness of individuals to donate has not yet been determined.

Humans↗

PubMed1978

Kidney-graft rejection: has the need for steroids to be re-evaluated?

In a group of azathioprine-treated patients whose renal allografts functioned immediately, 53 received prophylactic steroid treatment while 54 were given steroids only at the onset of the first renal failure. Three types of renal failure were identified, and their distribution in the patient groups was different, but the incidence of both reversible and irreversible renal failure episodes was identical in the two groups, suggesting that steroid treatment of early rejection episodes may not be necessary.

Azathioprine↗

PubMed1984

Renal transplantation after removal and prevention of resynthesis of HLA antibodies.

Plasma exchange and immunosuppression with prednisolone and cyclophosphamide were used to remove HLA antibodies and prevent their resynthesis in five patients awaiting renal transplantation. After treatment HLA antibody titres and reactivities against a panel of donor lymphocytes were considerably reduced and, as a result, these patients received transplants. Four of these patients have successfully functioning transplants; the other patient died as a result of septicaemia with a poorly functioning allograft.

Adolescent↗

PubMed1996

Association between specific HLA combinations and probability of kidney allograft loss: the taboo concept.

BACKGROUND: HLA matching improves the outcome of cadaveric renal transplantation. However, many allografts function well even in the presence of one or more HLA mismatches, which raises the question of whether some mismatches are better recognised by the recipient's immune system than others. We aimed to identify mismatched HLA donor-recipient combinations that were associated with increased graft loss. METHODS: We selected 2877 first, unrelated renal transplants with a single HLA A, B, or DR mismatch, undertaken between 1982 and 1992, from the Eurotransplant database. To enhance statistical power the analysis was restricted to mismatches of an HLA antigen that occurred in 100 or more donors. 1342 transplants met this criterion and were grouped into a definition set (n = 873) and a validation set (n = 469). In the definition set, we studied further only those recipient HLA antigens that occurred in at least 30 cases within each donor antigen mismatch subset. By a Cox proportional hazards model, donor-recipient combinations that led to significantly higher graft loss than in the whole group were defined. Such combinations were classified as taboo; the remaining combinations were classified as indifferent. FINDINGS: 106 individual recipient antigens were found at least 30 times with a corresponding donor mismatch in the definition set; 11 of the 106 had a significant effect on graft survival. Seven combinations were classified as taboo. Taboo combinations, confirmed as such in the validation set, were associated with graft survival of 81% at one year and 50% at 5 years, significantly lower than the rates in the group with indifferent combinations (89% and 69%; p = 0.04) or among 1190 recipients with no mismatches (89% and 72%; p = 0.03). The findings were substantiated by a multivariate analysis that included the effect of patient immunisation, cold ischaemia time, age, and sex. INTERPRETATION: Mismatched donor antigens are differentially recognised depending on the HLA phenotype of the recipient. The findings may have important clinical consequences for graft survival after transplantation.

Cadaver↗

PubMed1998

Pregnancy after liver transplantation.

This article reviews the reported experience with pregnancy after liver transplantation and describes obstetric risks and medical issues that the maternal fetal medicine specialist has a reference for managing these pregnancies and for providing appropriate preconception counseling. Women who undergo liver transplantations have a higher risk of preeclampsia, worsening hypertension, preterm premature rupture of membranes, anemia, small for gestational age, preterm delivery, and cesarean section than the normal obstetric population. Women with preconceptional renal dysfunction appear to be at greatest risk for pregnancy complications. Women who conceived within 6 months of transplant had a high risk of rejection. Reproductive-aged recipients of liver allograft should receive contraception and preconception counseling. In an appropriately timed and planned pregnancy, women who undergo liver transplantations can have successful pregnancies with little risk to their allograft function.

Contraception↗

PubMed2001

Broken kidney: traumatic fracture of a renal allograft.

Although many renal transplant recipients are protective of their grafts and often express concern about the possibility of traumatic injury, such injury has been reported only rarely. We describe a case report of a boy who sustained an injury to his renal allograft after a bicycle accident. Despite a dramatic anatomic abnormality seen on magnetic resonance imaging, he suffered only minor and self-limited symptomatic and clinical consequences. We reviewed the literature addressing traumatic injuries affecting renal allografts. The long-term consequences of such injuries on allograft function and survival are unknown.

Accidents, Traffic↗

PubMed2003

Successful treatment of mucormycosis peritonitis with liposomal amphotericin B in a patient on long-term peritoneal dialysis.

A 42-year-old man, with a history of immunoglobulin A nephropathy, underwent a living-related kidney transplant. Allograft function progressively deteriorated secondary to chronic rejection and recurrence of IgA nephropathy, and he returned to peritoneal dialysis after 5 years of the transplant. Fifteen months after the discontinuation of immunosuppressive therapy, Eschericia coli peritonitis developed, which was treated with ceftazidime intraperitoneally; he received fluconazole as prophylactic antifungal therapy during this period. After completing his course of treatment, abdominal pain occurred with an increased peritoneal fluid white blood cell count. Peritoneal fluid cultures were negative. He received broad-spectrum antibiotics and fluconazole with no appreciable response. After removal of the Tenckoff catheter, peritoneal fluid cultures grew a zygomycete. The patient was treated with liposomal amphotericin B (AmBisome) intravenously for 6 weeks. He had episodes of recurrent intraabdominal abscesses requiring surgical drainage and antibiotics. A second course of liposomal amphotericin B was administered for histopathologic evidence of filamentous fungal recurrence. After 5 months, the patient remains well without any evidence of infection.

Abdominal Abscess↗

PubMed2001

Quantitative heel ultrasound in assessment of bone structure in renal transplant recipients.

Many patients with advanced renal disease have osteopenia or even osteoporosis by the definition of the World Health Organization based on bone mineral density (BMD). Dual-energy X-ray absorptiometry (DXA), the standard method to assess BMD, is not always available. Quantitative heel ultrasound (QUS) is an inexpensive, mobile, and radiation-free diagnostic alternative, yet few data address this method's usefulness in patients with renal disease. The present study assessed the value of QUS in detecting changes in bone structure in renal transplant recipients compared with DXA. In a cross-sectional analysis, 50 patients (29 women) with a mean age of 50 +/- 13 years, mean time since transplantation of 60 months (range, 1 to 205 months), and stable renal allograft function were studied. BMD was quantified by DXA of the hip and spine. QUS of the left heel measured broadband ultrasound attenuation (BUA) and speed of sound (SOS). Stiffness index (SI) was calculated as SI = (0.67 * BUA + 0.28 * SOS) - 420. DXA measurements established the diagnoses of osteopenia and osteoporosis in 49% and 22% of the patients, respectively. Femoral neck BMD and QUS parameters showed good correlation (r = 0.638; P < 0.001). Sensitivities of BUA, SOS, and SI for diagnosing osteoporosis were 100%, and specificities were 73%, 76%, and 78%, respectively. Positive predictive values were 50%, 53%, and 56%, and negative predictive values were 100%. QUS can be recommended for screening patients who do not have osteoporosis. Those suspected of osteopenic bone structure should be examined by additional DXA measurement for quantification before initiation of therapy.

Absorptiometry, Photon↗

PubMed1994

Chronic renal failure secondary to 2,8-dihydroxyadenine deposition: the first report of recurrence in a kidney transplant.

We report a case of adenine phosphoribosyltransferase deficiency in which the initial presentation was chronic renal failure. Diagnosis was made after infrared microscopy analysis of microcrystalline deposits on a kidney allograft biopsy specimen. This type of presentation is rarely seen, the most frequent manifestation of this disease being urolithiasis. This is the first report of recurrence of the microcrystalline nephritis in a kidney transplant with subsequent loss of allograft function.

Adenine↗

PubMed1985

Clinical experience with cyclosporine and azathioprine at Brigham and Women's Hospital.

Cyclosporine (CsA) immunosuppressive therapy of renal allograft recipients at Brigham and Women's Hospital yielded a 20% increase in 12- and 24-month allograft survival over azathioprine (Aza) treated controls. A trend towards increased allograft survival with better HLA-A,B, or DR matching in recipients of cadaver allografts treated with CsA was appreciated, but it fell short of statistical significance. Nephrotoxicity is common in CsA-treated patients and is manifested by a largely reversible increase in the serum creatinine. It is possible to convert patients from CsA to Aza without adverse effects on allograft survival or allograft function.

Adult↗

PubMed1985

Examination of parameters influencing the benefit:detriment ratio of cyclosporine in renal transplantation. The Canadian Transplant Study Group.

The benefit:detriment ratio of Cyclosporine (CsA) in renal transplantation was examined by analysis of the data accumulated within the Canadian Transplant Study Group (CTSG). Transplantation was performed according to commonly defined protocols, and 496 patients were analysed following cadaveric or live-related transplantation. One-year patient and graft survival were 96% and 86%, respectively, following living-related HLA nonidentical transplantation, 92% and 75% following primary cadaveric transplantation, and 97% and 58% following cadaveric retransplantation. A clear beneficial effect of blood transfusion was observed following primary cadaveric renal transplantation (P = 0.04), with a trend towards improved graft survival in donor/recipient pairs matched at the B or Dr locus (89% v 73%, P = NS). Prolonged machine preservation (greater than 24 hours) of the kidney or long (greater than than 45 minutes) surgical anastomosis time, and an elevated serum CsA level adversely influenced allograft function. Graft function in patients receiving CsA stabilized by approximately 6 months posttransplant, and subsequently remained constant as determined by both serum creatinine and calculation of creatinine clearance. Hypertension was more common (P = 0.003) in patients receiving CsA, and vascular complications were more frequent although this difference was not statistically significant. Infectious complications were comparable between the two groups. Two lymphomas were confirmed in patients receiving CsA. The mean cost of CsA throughout the first 12 months posttransplant based on a 60 kg patient weight was $4,490, and reduced by $3,397 each subsequent year of maintenance treatment.

Adolescent↗

PubMed1986

Pulmonary calcinosis after renal transplantation in pediatric patients.

Pulmonary calcinosis is a recognized complication of renal failure. The resulting pulmonary compromise may be severe or even fatal. The potential contribution of hypercalcemia, hyperphosphatemia, and increased calcium-phosphorus product to the development of pulmonary calcinosis has been controversial. We describe four patients (ages 2 1/4 to 18 years) who had severe pulmonary calcinosis and respiratory failure within three to five days after renal transplantation. Initial clinical and roentgenographic findings suggested noncardiogenic pulmonary edema. Marked pulmonary hypertension was present in the two patients in whom pulmonary artery pressure data were available. Other clinical features in common included poor allograft function with persistent uremia requiring dialysis and evidence of moderate to severe secondary hyperparathyroidism. In three of the patients, the calcium-phosphorus product increased markedly after transplantation, to peak values of 122 to 147. This increase occurred at the same time as the onset of respiratory failure. Peak serum calcium levels were 10.0 to 11.0 mg/dL and peak serum phosphorus levels were 9.2 to 13.5 mg/dL. All patients died of respiratory failure five to 58 days after transplantation. The posttransplantation period may be a time of increased risk of potentially fatal pulmonary calcinosis in pediatric renal transplant recipients. The diagnosis should be considered in any patient with respiratory failure of unknown cause following renal transplantation.

Adolescent↗