Alain Duboust

Desensitization and Subsequent Kidney Transplantation of Patients Using Intravenous Immunoglobulins (IVIg)

Transplantation of patients possessing antibodies against allo‐HLA antigens can be delayed for years. We have shown that administration of intravenous immunoglobulins (IVIg) can induce a profound and sustained decrease in the titers of anti‐HLA antibodies. We report here the first series of patients desensitized, then transplanted using IVIg therapy. Fifteen patients have been included and treated with IVIg, given as 3 monthly courses of 2 g/kg body weight. Thirteen of those 15 patients (87%) were effectively desensitized and underwent immediate transplantation. Eleven were transplanted with a cadaveric donor, and two with a living donor against which the pretreatment cross‐match was positive. One graft was lost from thrombosis and one from rejection. All other patients had uneventful courses, without any episodes of rejection, with a follow‐up of more than 1 year. Thus, IVIg therapy allows safe and prompt kidney transplantation of immunized patients.

ARTIFICIAL URETERAL REPLACEMENT FOR URETERAL NECROSIS AFTER RENAL TRANSPLANTATION: REPORT OF 3 CASES

PURPOSE We applied a new minimally invasive technique of artificial ureteral replacement for renal transplant ureteral necrosis. MATERIALS AND METHODS Artificial ureteral replacement was performed in 3 renal transplant recipients with ureteral necrosis (complete in 1 and distal in 2) after failure of primary endoscopic treatment. Under fluoroscopic guidance a percutaneous tract is created and progressively dilated. The ureteral silicone polytetrafluoroethylene bonded tube is introduced into the pyelocaliceal renal graft cavities, tracked subcutaneously down to the suprapubic area and introduced into the bladder via a short incision. RESULTS There were no immediate postoperative complications except for transient postoperative acute prostatitis in 1 patient. No secondary complications were observed with a mean followup of 2.5 years. All grafts have good late function and all tubes are patent with no evidence of encrustation or obstruction. The tubes are well tolerated underneath the skin. Reflux was present in all 3 cases with no clinical manifestation. An asymptomatic episode of lower urinary tract infection was observed in the female patient. CONCLUSIONS In select cases of ureteral necrosis after renal transplantation artificial ureteral replacement by subcutaneous pyelovesical bypass offers a possible alternative to open ureteral reconstruction.

Antidonor antibodies and transplantation: how to deal with them before and after transplantation.

The presence of antibodies directed against the donor has usually been considered as an absolute contraindication to transplantation. However, recent advances both in the ABO and human leukocyte antigen settings, detailed in this paper, have led to successful transplantations in the presence of antidonor antibodies, with preliminary evidence of accommodation.

Total ureteral replacement by subcutaneous pyelovesical bypass in ureteral necrosis after renal transplantation

Abstract Objectives: Ureteral necrosis is a rare complication of renal transplantation, and is seldom cured by endoscopic management alone. To avoid the potential hazard to the graft created by an open ureteral reconstruction in cases of renal transplant ureteral necrosis, we have appiled a new minimally invasive technique of total ureteral replacement, initially described for the palliative treatment of ureteral obstructions. The subcutaneous bypass technique is based on the use of a silicone‐PTFE‐bonded tube tunnelled underneath the skin. Methods: Total ureteral replacement by subcutaneous pyelovesical bypass was performed in three renal transplant patients (two men and one woman; mean age 41 years, (range 23–58) years with ureteral necrosis after failure of primary endoscopic treatment. The ureteral lesion was distal necrosis in two patients, and a total necrosis in the other. Under general anaesthesia and fluoroscopic guidance, a percutaneous tract was created and progressively dilated. The ureteral prosthesis was introduced into the pyelocaliceal cavities through a 30 F Amplatz sheet, then subcutaneously tracked down to the suprapubic area, and introduced into the bladder via a short incision. Results: There was no operative or postoperative morbidity. There was no obstruction, dislodgement or encrustation of the prosthesis. There were no bladder‐related symptoms, or clinical reflux, and no abdominal wall complications. An asymptomatic episode of lower urinary tract infection (Staphylococcus epidermidis) was observed in the female patient. All the grafts were functioning with fine pyelocaliceal cavities, with a mean follow‐up of 32 months (13–69 months). Conclusion: Total ureteral replacement by subcutaneous pyelovesical bypass is a simple and safe technique of ureteral reconstruction in renal transplantation. Late encrustation of the prosthesis may occur, and the prosthesis may need to be changed in such cases. Subcutaneous pyelovesical bypass can be regarded as an alternative to an open procedure to treat ureteral necrosis after renal transplantation.

Calcineurin inhibitor-free monotherapy in human leukocyte antigen–identical live donor renal transplantation.

Background. Most recent trials in human leukocyte antigen (HLA)-identical living donor (LD) renal transplantation have used immunosuppressive regimens with no induction therapy, corticosteroid-free long-term treatment, and calcineurin inhibitor minimization. Patients and Methods. Seven HLA-identical LD recipients were prospectively enrolled. Immunosuppression included induction therapy with antithymocyte globulins for 10 days and long-term monotherapy with mycophenolate mofetil (2 g/day) in six cases and sirolimus (target trough levels: 6–10 ng/mL) in the last case. A single preoperative steroid bolus was administered. Results. After a median follow-up time of 26 months (range: 5–50 months), patient and graft survival was 100%. Only one patient experienced borderline lesions at 3 months and received steroids for a 5-month period. All patients had a protocol biopsy at 3 months, and four had a second at 12 months. Acute cellular rejection was not observed. Median serum creatinine at 3 months, 12 months, and last follow-up were 103.1, 107.1, and 106.1 &mgr;mol/L, respectively. For four patients, measured glomerular filtration rate was evaluated at 3 months, and the mean value was 71.2 mL/min/1.73 m2. Conclusions. Induction therapy with antithymocyte globulins followed by mycophenolate mofetil or sirolimus monotherapy provides excellent patient and graft survival, excellent renal function, and no acute rejection episodes in HLA-identical LD renal transplant recipients.