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PubMed1992

Duplex evaluation of native renal vessels and renal allografts.

Duplex ultrasound and color duplex imaging are useful in evaluating the renal vasculature. Investigation of native renal vessels includes the diagnosis of renal artery stenosis and occlusion and renal vein thrombosis. The sonographic examination of renal allografts may detect vascular complications and peritransplant fluid collections, both of which may impair allograft function. In order to perform and interpret renal vascular sonography, knowledge of pertinent vascular anatomy and proper duplex technique is essential. Renal arterial and venous examination with gray-scale, Doppler, and color duplex imaging is reviewed, comparing their performance with other methods of assessing renal vessels when appropriate.

Carcinoma, Renal Cell↗

PubMed2005

Preventing renal transplant failure.

INTRODUCTION: Allograft failure due to immunological or non-immunological causes or a combination and patient death after transplantation are the 2 major causes of renal transplant loss. This paper reviews the various causes of allograft failure and explores strategies for its prevention. RESULTS: Immune mechanisms of renal allograft failure are those mediated by acute and chronic rejection and are initiated by human leukocyte antigen (HLA) disparity between donor and recipient and increased recipient immune responsiveness that results in pre-sensitisation against HLA antigens. Better HLA matching between donor and recipient in both live-donor and cadaveric renal transplant recipients and the use of more potent immunosuppressants has reduced the incidence of acute rejection and resulted in improved overall graft survivals in recent years. However, as the use of more potent immunosuppression increases the risk of infections and malignancy, tailoring therapy by administering more potent immunosuppression to those at higher immunological risk may result in a better balance between the risks and benefits of immunosuppressive therapies. Ischaemia of the donor kidney, calcineurin inhibitor (CNI), mediated nephrotoxicity, reduced renal mass, hypertension, hyperlipidaemia and infections contribute to allograft failure through non-immunological mechanisms. Indeed, any cause of renal injury that results in nephron loss, either immunological or non-immunological, leads to reduced renal mass and initiates further renal damage due to hyperfiltration. Optimising these factors and minimising CNI nephrotoxicity are critical in reducing chronic allograft failure. CONCLUSIONS: Optimising each of these time-dependent and immunosuppressive drug-related factors would allow the maximization of renal allograft function and survival.

Animals↗

PubMed2004

Pregnancies in renal transplant recipients--with a focus on the maternal issues.

One hundred and thirteen pregnancies in 73 women who received a renal transplant were studied. The duration between the transplant operation and the conception averaged 19.9 months with a range of I month to 72 months. The mean age was 28 years. The majority (50 recipients had one pregnancy each, but two women had 5 children each and one had seven children). Only 12 (11.5%) out of the 113 pregnancies ended up with spontaneous abortions. The maternal medical problems encountered were reversible rejection in 11%, hypertension in 43%, UTI in 17% and gestational diabetes in 21%. It was noted that there was high incidence of preterm delivery in 64% of the pregnancies Caesarian section was required in 72% % of the cases. In conclusion we observed a high prevalence of successful pregnancies with no adverse effect on the allograft function and excellent fetal outcome (which is described in a separate paper focusing on the fetal outcome).

Abortion, Spontaneous↗

PubMed2005

Acute kidney transplant failure following transurethral bladder polyp fulguration.

Ureteral obstruction and anastomotic leak represent the most common urologic complications of kidney transplantation. Delay in diagnosis or treatment can lead to allograft loss. Obstruction of the ureter occurs in 2% of kidney transplant recipients. Although the majority of cases are immediate technical complications of the operation, subsequent manipulation of the genitourinary system can result in iatrogenic ureteral injury. We report the case of a long-term kidney transplant recipient who developed obstructive uropathy and acute renal failure requiring dialysis after undergoing cystoscopy and bladder polyp fulguration. The etiology was inadvertent thermal injury of the ureteroneocystostomy incurred during the procedure. After attempted percutaneous management, definitive open repair resulted in a return of allograft function to baseline.

Acute Kidney Injury↗

PubMed2005

Kaposi's sarcoma in renal transplant recipients.

Kaposi's sarcoma (KS) is a spindle-shaped vascular cell tumor that occurs in the skin, lymphoid, respiratory and gastrointestinal tissues. It may resemble aggressive malignant neoplasm in HIV-related or in post-transplant types but classic form may behave as benign, potentially controllable and reversible hyperplasia. KS lesions from the onset are dispersed and multicentric. KS probability increases in solid organ transplant recipients (approximately 3/1000 patients). KS occurrence is associated with: type and dose of immunosuppression, chronic stimulation by foreign allograft antigens, viral infections (Herpes virus 8), anti rejection and induction therapy, etc. 90% of KS cases appear as dark blue or purplish macular lesions that may form nodular tumors. Histological picture shows networks of spindle shaped cells and vascular spaces surrounded by an endothelial cell layer. There is no uniform schema of KS treatment in renal transplant recipients. Immunosuppression must be reduced to the lowest levels which preserve allograft function. CsA should be converted to mofetil mycophenolate or mTOR-inhibitors. After conversion to MMF regression of KS was observed, although low therapeutic MMF doses seem to be appropriate. Sirolimus seems to inhibit the growth of established vascularized tumors and this effect is best realized with relatively low immunosuppressive doses of drug.

Herpesvirus 8, Human↗

PubMed2005

Severe Mg-deficiency is not associated with endothelial cell activation in mouse lung.

Several experimental and clinical studies suggest that the lungs are a specific target of Mg-hypomagnesemia, which is a common side effect of cyclosporin A therapy. Due to the possible effect of hypomagnesemia on lung allograft function, the aim of this study was to evaluate endothelial cell (EC) activation and tissue remodelling (apoptosis) in the lungs from mice fed Mg-deficient diets. Immunocytochemical examinations did not reveal any inflammatory process in Mg-deficient mice, infiltration of leukocytes (CD45+ cells), expression of I-Ab class II molecules, E-selectin or ICAM-1 on ECs, and apoptotic cells. Quantification of mRNAs for E-selectin, ICAM-1 and VCAM-1, which are the most pertinent adhesins expressed by ECs, and for the cytokines TNFalpha and IL-2, demonstrated that severe Mg-deficiency does not result in EC activation. The balance between the up-regulation of G-CSF-R and CCL4 genes, and the down-regulation of the OPN gene shown by the cDNA microarray technique might be responsible for the absence of development of an inflammatory response, lung EC activation, and lung remodelling. However, we can hypothesize that severe Mg deficiency results in a latent inflammatory status of the lungs, which might be expressed following immune stresses, like transplantation conditions.

Animals↗

PubMed1992

Normocalcemia thirteen years after successful parathyroid allografting in a recipient of a renal transplant.

Two months after receiving a cadaveric renal allograft, a 36-year-old woman received a parathyroid allograft from a living unrelated donor, who was haploidentical to the renal donor. Her preoperative 24-hour urinary excretion of calcium was 0.18 gm/24 hrs, and after operation it decreased to 0.004 gm/24 hrs, (normal, less than 0.20 gm/24 hrs). The C-terminal parathyroid hormone level increased from 155 pg/ml (normal, 275 to 675 pg/ml) to 327 pg/ml after operation. The N-terminal parathyroid hormone level in her grafted arm has varied between 2.5 to 10 times the level in her nongrafted arm. Thirteen years later, both allografts are functioning normally. To our knowledge, this is the longest functioning parathyroid allograft.

Calcium↗

PubMedDate not supplied

Increased perioperative lung preservation injury with lung procurement by Euro-Collins solution flush.

In 47 donor organ procedures for heart-lung transplantations, lungs were preserved by autoperfusion in 21 cases and by Euro-Collins solution flush in 26 cases. Criteria used to diagnose inadequate allograft function included radiographic interstitial and alveolar infiltrates and an alveolar-arterial oxygen gradient significantly greater than 100 mm Hg at 24 hours after surgery. Oxygen gradients were calculated intraoperatively, on arrival in the intensive care unit, and during the first 24 hours after surgery. With these criteria, 15 patients with perioperative preservation damage were identified. They were compared with 32 patients without evidence of preservation injury. Patients with preservation injury showed persistently elevated alveolar-arterial oxygen gradients that were significantly above noninjury values at all times (p less than 0.03). There was no difference in donor organ ex vivo time between the two groups (227.8 +/- 74.4 vs 169.5 +/- 76.9, p = NS). The incidence of perioperative preservation injury was significantly greater among patients in the Euro-Collins solution group (12/26) than in patients with autoperfusion (3/21) (p = 0.04, Fisher's exact test). Three of the 15 recipients died of primary lung graft failure. In our hands, preservation by use of a modified Euro-Collins solution flush technique has led to unpredictable results in lung transplantation.

Adolescent↗

PubMed1990

Experience with renal transplantation in the second and third decades at the Hennepin County Medical Center.

Approximately one-third of the patients receiving renal transplants have functioning allografts at 10 years. Chronic rejection continues to be the leading cause of kidney loss in late survivors. Atherosclerotic cardiovascular disease, liver failure, malignancy, and sepsis are the major causes of late death. Identification and control of the risk factors contributing to patient mortality should enhance the long-term success of renal transplantation.

Female↗

PubMed1990

Successful renal transplantation accelerates development in young uremic children.

To examine the impact of renal transplantation on subsequent development of children with chronic renal failure, 37 children undergoing primary renal transplantation at or before 30 months of age whose allograft functioned for at least 1 year were prospectively studied. Psychometric tests were performed an average of 4 months before transplantation; reevaluation was done an average of 14 months after surgery. Comparison of individual pretransplantation and posttransplantation mental development scores in 33 patients, assessed by either Bayley Mental Development Index or Stanford-Binet Intelligence Quotient, revealed an average increase of 12.6 (P less than .001). After transplantation, there was a significant improvement in mental performance in 12 of 18 patients (P less than .02) from the range of mild delay (Mental Development Index or Stanford-Binet IQ score = 50 to 69) to the range of normal mental development (greater than or equal to 70). The Bayley Psychomotor Development Index scores were frequently lower than Mental Development Index scores and also increased an average of 14.4 (P less than .01) after transplantation in all 12 patients with paired data. Significant individual improvement in occipital-frontal circumference standard deviation score (P less than .001) was noted in 24 children after transplantation. It is concluded that successful renal transplantation in young children with chronic renal failure is often associated with significant improvements in cognitive and psychomotor function, as well as improved cephalic growth.

Child Development↗

PubMed1979

Somatomedin and growth hormone studies in pediatric renal allograft recipients who receive daily prednisone.

Plasma somatomedin (SM) activity and growth hormone (GH) concentration were measured in ten growth-retarded, well-nourished pediatric renal allograft recipients who received daily prednisone therapy. The SM activity ranged from 0.21 to 1.22 micron/mL, and it was subnormal in three patients. A significant correlation was found between SM activity and creatinine clearance. Serial SM levels were determined during a 24-hour period in five patients; SM activity decreased at six and 12 hours and returned to normal values by 24 hours. The 24-hour plasma GH concentrations ranged from 1.5 to 7.6 mg/mL. Peak GH concentrations ranged from 2.1 to 14.2 ng/mL after insulin-induced hypoglycemia and from 1.8 to 24.6 ng/mL after oral glucose loading. Sleeping GH peaks were absent in two patients. These results suggest that growth failure in renal allograft recipients who receive daily prednisone may result from (1) partial GH deficiency, (2) reduced SM levels owing to diminished allograft function, and (3) daily transient decrease in plasma SM levels after prednisone administration.

Adolescent↗

PubMed1990

Predictive value of intraoperative liver biopsies of donor organs in patients undergoing orthotopic liver transplantation.

The evaluation of prerevascularization and postrevascularization biopsies in comparison with clinical and laboratory data has revealed a direct correlation between elevated PT and AST levels and pericentral and panlobular individual hepatocyte necrosis. No other significant correlations were determined when comparing selected histologic features to selected clinical laboratory values. In conclusion, these biopsies are of limited use in predicting subsequent allograft function in the absence of prominent individual hepatocyte or pericentral necrosis.

Adult↗

PubMed1975

Heart transplantation in endotoxin shock.

The condition of the heart from dogs in endotoxin shock was evaluated, and all dogs in the control group receiving 5 milligrams per kilogram to Eschericia coli endotoxin died within two to 14 hours. Hearts from four other dogs receiving the same dosage of endotoxin were allografted orthotopically into healthy recipient dogs. The donor heart was taken in the terminal phase of shock, after the blood pressure of the donor had declined to 50 millimeters of mercury or less. All four heart allografts functioned normally in the healthy hosts, demonstrating that lethal levels of gram-negative endotoxin do not produce direct irreversible damage to the myocardium or to the conduction mechanism of the heart. This also was shown in one pair of monkeys; the donor monkey had received ten times the dosage of endotoxin used in the dogs. This heart transplant model offers considerable advantage in functional studies of the heart after irreversible shock.

Animals↗

PubMed1990

[Results of conversion from conventional immunosuppressive therapy to cyclosporin A in complications following kidney transplantation].

In 41 patients suffering from complications late after kidney transplantation the conventional immunosuppression was converted to Cyclosporin A. A complete normalization was obtained in the case of acquired immunoglobulin G deficiency and in persistent leukocytopenia. 6 patients suffering from life-threatening bacterial infections did survive after conversion with functioning allograft and 8 out of 9 late rejections were reversible. Conversion may be necessary in chronic hepatopathy and chronic rejection. A conversion to cyclosporin A is recommended because of control of complications in 78% (46/59) of the recipients.

Adolescent↗

PubMedDate not supplied

Renal transplantation: results in hemodialysis patients previously treated with recombinant human erythropoietin.

The eventual commonplace use of recombinant human erythropoietin (r-HuEPo) for the treatment of the anemia associated with chronic renal failure will have definite consequences in the dialysis supported patient. The effect of this nonanemic state on renal transplantation, both in the early posttransplant period as well as the waiting period, was examined in this study. Thirteen of 16 patients who were treated with the hormone and subsequently underwent cadaveric renal transplantation (Tx) were compared to control transplant patients from a typical chronic renal patient population. There seemed to be no difference in the length of hospital stay, need for dialysis support post-Tx, or severity of acute post-Tx renal failure as measured by the days of dialysis support given. Furthermore, there seemed to be no evidence of marrow unresponsiveness to endogenous erythropoietin produced by the functioning allograft, so that after an initial fall in hemoglobin and hematocrit, these parameters returned to normal levels at three to six months. HLA antibody production was also tracked over the course of chronic r-HuEPo therapy, and the response followed one of three patterns: (a) initially very high (100%) or very low (less than 15%) and showed no change; (b) moderate to high reactivity fell to lower levels with time; or (c) some stimulation noted without recent blood transfusions. Thus, patients entering end-stage renal failure without having been exposed to transfusions can be maintained in a low antibody state and perhaps increase the cadaveric kidneys available to them. Therefore, r-HuEPo therapy in patients who will subsequently undergo transplantation seems to have no deleterious effect on patient morbidity, or transplant outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Urea Nitrogen↗

PubMed1989

[Long-term results following surgical treatment of tetralogy of Fallot].

The few published long-term studies regarding survival after corrective surgery of tetralogy of Fallot are based on patients operated 15 to 30 years ago during the developmental phase of the corrective technique. Interpretation of the results and conclusions for the present time based on these interpretations are thus difficult. It should be possible, however, to improve the reported life expectancy of less than 90% after 15 to 30 years for those who survived corrective surgery. Preservation of myocardial function, especially that of the right ventricle is most important for the improvement of life expectancy. Influencing factors are - besides degree of severity and duration of preoperative overload - residual defects, sequela and complications. The classical residual defects such as ventricular septal defect or stenosis of the right ventricular outflow tract are rarely observed today. Cardiac complications such as AV-block and arrhythmia may not always be preventable; local and diffuse fibrotic alterations of the right ventricular myocardium are probably the cause, which in turn may be induced by ventriculotomy, infundibulectomy as well as pressure overload and hypoxemia. Duration of overload is most likely the main contributing factor. The most important sequela is the postoperative pulmonary insufficiency. The larger the volume overload the more pronounced is the impairment of right myocardial function. Allograft implantation appears to be the most promising technique to prevent pulmonary insufficiency at the present time.

Adolescent↗

PubMed1989

Agonal hepatic arterial vasospasm.

The effect of donor pretreatment with Dibenzyline (phenoxybenzamine) on hepatic arterial vasospasm was studied in a porcine asphyxia model. Nine pigs underwent hepatectomy without pretreatment, while six were given 2 milligrams per kilogram of Dibenzyline prior to hepatic dissection. Hepatic arterial blood flow was monitored with an electromagnetic flow probe, and after cardiac arrest, arteriograms of the hepatic circulation were obtained. Hepatic arterial vasospasm occurred in seven of the pigs in group 1 and in only one of group 2 (p less than 0.05). Agonal hepatic arterial blood flow remained constant (415 +/- 30 milliliters per minute) in pretreated pigs during asphyxia, but was markedly reduced (98.6 +/- 63.3 milliliters per minute) in nonpretreated pigs (p less than 0.05). Results of this study demonstrate the agonal occurrence of hepatic arterial vasospasm and its prevention with Dibenzyline. Donor pretreatment with alpha-adrenergic antagonists may be indicated in clinical organ procurement to prevent agonal arterial vasospasm and its potentially adverse effect on early hepatic allograft function.

Animals↗

PubMed1987

Renal transplant patients treated with total lymphoid irradiation show specific unresponsiveness to donor antigens the mixed leukocyte reaction (MLR).

A group of 25 cadaveric renal transplant recipients received total lymphoid irradiation (TLI) before transplantation, rabbit anti-thymocyte globulin on alternate days for 10 days after transplantation, and low dose prednisone (5 to 10 mg/day) as the sole maintenance immunosuppressive therapy. Allograft function and the mixed leukocyte reaction (MLR) were monitored serially. After 18 to 30 mo, nine patients were selected on the basis of a return of the MLR such that the mean stimulation index to a panel of normal stimulator cells was greater than or equal to 5, a stable serum creatinine level which was less than or equal to 2 mg/dl, and a history of no more than one rejection episode. The MLR of these patients' post-transplant peripheral blood mononuclear leukocytes (PBML) against cryopreserved donor cells was compared with that against cryopreserved normal third-party cells. In control experiments, the MLR of cryopreserved pre-TLI recipient PBML or fresh normal PBML were tested against the same panel of donor and third-party stimulator cells. Seven of the nine recipients showed a pattern of specific unresponsiveness to the donor cells more than 18 mo after transplantation. Preliminary attempts to identify antigen specific suppressor cells were unsuccessful. The pattern of unresponsiveness may indicate a state of specific immune tolerance to the allogeneic graft.

Adult↗