Dai D. Nghiem

Technique of simultaneous renal pancreatoduodenal transplantation with urinary drainage of pancreatic secretion

There are many advantages to transplanting the pancreas in the right iliac fossa and draining the pancreatic exocrine secretions into the bladder. This technique has been performed successfully in nine patients and the details have been discussed herein.

Metabolic effects of urinary diversion of exocrine secretions in pancreatic transplantation.

We have compared the metabolic consequences of two forms of exocrine drainage for pancreaticoduodenal transplant, duodenojejunostomy (DJ) and duodenocystostomy (DC). DC offered the advantage of avoiding opening of the recipient small intestine with its potential for wound sepsis, as well as a reliable method for early detection of pancreatic rejection as measured by an abrupt fall in urinary amylase and bicarbonate concentration. However, DC led to a large urinary loss of bicarbonate with a concomitant mild metabolic acidosis. During periods of renal dysfunction, the patients with DC developed severe hyperchloremic acidosis. Use of DC for pancreatic exocrine diversion may require patients to take supplemental bicarbonate even with a well-functioniong renal transplant.

Factors influencing male sexual impotence after renal transplantation

Sexual impotence has been reported sixfold after sequential renal transplantation. The effects of race, age, diabetes mellitus, hypertension, uremia, arteriosclerosis (by ABI = ankle BP/brachial BP), penile blood flow (by PBI = penile BP/brachial BP), length of dialysis and transplantation, and patency of hypogastric arteries (by angiogram and operative description) on impotence were examined in a retrospective study of 61 male transplant patients followed from six to 108 months and a prospective study of 15 patients evaluated before and after transplantation with a six-month follow-up. Age (greater than forty years) was the only factor deleterious to male potency (potent patients 40.1 +/- 10.40 years vs impotent patients 48.6 +/- 10.06 years significant at p less than 0.006). Impotence did not correlate with ABI and PBI. Interruption of both hypogastric arteries is not necessarily related to impotence. Vascular impotence is more uncommon in renal transplant recipients than we had anticipated. Post-transplantation male impotence is perhaps best treated by penile prosthesis insertion.

Incidence and morbidity of cytomegalovirus disease associated with a seronegative recipient receiving seropositive donor-specific transfusion and living-related donor transplantation: A multicenter evaluation

This retrospective study was conducted to identify the frequency of cytomegalovirus (CMV) disease in seronegative recipients of donor-specific transfusion (DST) and living-related donor (LRD) kidneys from seropositive donors. A total of 151 LRD transplants (TX) were performed at six transplant centers over a 3-year period. A total of 33 patients were identified as having been seronegative (pre-TX) for CMV, yet they had DST and a TX from a seropositive LRD. of these patients, 12 (36.45%) seroconverted within the first 6 months post-TX and developed clinical CMV disease. Additional patients seroconverted, but did not have evidencde of clinical disease and were not tested further. All TX centers, with the exception of one, had seronegative patients that became ill after receiving a seropositive DST/LRD TX. Six patients manifested their disease as a febrile illness with leukopenia and liver enzyme elevations, four had pneumonitis, and two developed CMV ulcerations of the colon (one of whom died from resultant sepsis). Of the 36 seronegative patients who received seronegative DST/LRD TX none became ill with CMV disease. Of the 72 seropositive patients who received DST/LRD TX, only 2 (2.8%) developed CMV illness (one, seropositive into seropositive, the other, seronegative into seropositive). Of the 33 seronegative patients receiving seropositive DST/LRD TX, 17 received antilymphocyte preparations (ALP), and 8 of these became ill (47.1%). Of 16 patients not receiving ALP, 5 (31.3%) developed clinical CMV illness. Of the 33 patients who were identified as having been seronegative for CMV seronegative for CMV yet received seropositive DST/LRD TX, the 12 who did develop CMV illness had two graft losses, one death, and a serum creatinine for the remaining 9 patients of 2.3pL1.6 at last follw-up. the remaining 21 patients who developed no illness had a serum creatining of 1.3pL0.6 with no graft losses at the last follow-up. This evidence suggests that a prospective TX recipient who is seronegative for CMV who received DST/LRD Tx from a seropositive family member has a significant risk for developing morbidity related to clinical CMV illness.

Failure of cyclosporine to prevent in vivo T cell priming in man. Studies in allogeneic spleen transplantation

Cyclosporine is a potent new immunosuppressive agent utilized in clinical organ transplantation. Available evidence suggest that it interferes with the secretion of interleukin-2. However, the long term efficacy of cyclopsorine in preventing allograft rejection may depend on a relative sparing of suppressor cells early in the allogeneic response, allowing them to mature and effect a state of operational tolerance. If this is the case, cyclosporine must not affect antigen priming or recognition. Two patients in our center underwent allogensic spleen transplant in conjunction with renal and pancreatic transplant. Both patients were treated with therapeutic levels of cyclosporine during the course of transplant. Neither developed any clinical signs of renal or pancreatic transplant rejection. Both patients developed graft-versue-host disease and eventually required allogeneic (donor) splenectomy. Studies performed on the splenocytes recovered from these specimens demonstrate alloantigen-specific cytotoxic T cell precursors. These studies demonstrate that although cyclosporine can prevent allograft rejection it does not necessarily prevent or ameliorate graft-versus-host disease. Furthermore, cyclosporine does not prevent in vivo T cell priming of alloantigen recognition. The primed cytotoxic precursors can be expanded in the presence of exogenous interleukin-2 to become fully active cytoxic cells.

Results of conversion from cyclosporine to azathioprine in cadaveric renal transplantation.

Between December 1983 and August 1985, 110 cadaver transplants were performed at our institution. All were started on cyclosporine (CsA) and prednisone (P) for immunosuppressive therapy. Of the 110 patients, 46 were converted from CsA to azathioprine (AZA) for a variety of reasons (cost, toxicity, patient preference, prolonged dysfunction posttransplant, or nonresponsive rejection). The course and outcome of these patients are described. The only group of patients who had consistent benefit and stable course following the CsA-to-AZA switch were primary cadaver transplants with stable renal function (serum creatinine less than 2 mg/dl) who were converted an average of 7.97 months posttransplant. All other groups of patients had severe problems or graft loss postconversion.

Effect of transfusion of donor on allograft survival.

It has been reported by two European transplant centers that blood transfusion of cadaver donors with third-party blood prior to nephrectomy increases renal allograft survival rates by approximately 30% at 1 year. A retrospective analysis in our center was performed on 293 kidney recipients, 110 of whom received kidneys from untransfused donors. Actuarial analyses revealed no significant differences in graft survival rates between all nontransfused donor kidneys and all transfused donor kidneys. Considering only first transplant recipients, there was no difference in graft survival rates between nontransfused donor kidneys and transfused donor kidneys. In addition, when only preoperatively transfused recipients receiving first transplants were examined, there was no difference in graft survival rates between nontransfused donor kidneys and transfused donor kidneys. Animal studies were performed with (Lewis Brown Nbrway) F1 (LBNF1) hybrid rat hearts transplanted heterotopically to the abdomens of Lewis rat recipients. Six LBNF1 heart grafts had a mean survival time of 8.0 ± 1.1 days. Five LBNF1 rats received 2 ml of heparinized whole blood from Charles River (CD) rats 24 hr before heart transplantation to Lewis recipients. The transfused LBNF1 grafts had a mean survival time of 6.6 ± 0.9 days. Therefore, donor blood transfusion does not appear to prolong graft survival in this retrospective human study or in the animal model.

Successful DR-incompatible cadaver kidney transplantation. Combined effect of HLA A and B matching and blood transfusion.

The purpose of this retrospective analysis of DR-in-compatible cadaver renal transplantation was to evaluate the effect of HLA A and B matching and blood transfusion status on actual one-year graft survival. There were 31 2-DR, 111 1-DR, and 27 0-DR grafts at risk during the study period. First, a comparison was made between preoperative (PRE) and peroperative (PER) transfusions alone. Graft survivals were 70% vs. 92% (2 DR), 67% vs. 52% (1 DR) and 71% vs. 39% (0 DR) for the PRE and PER groups, respectively. Statistical significance was not found between the two values in each DR subgroup, although the difference approached significance in the 0 DR group (0.1>P>0.05). Matching for ≥2 A and B antigens significantly improved graft survival in the 1 DR-matched group when compared with those matched for <2 antigens (76% vs. 44%, P<0.005). While marked differences between the ≥2 and <2 A and B matched groups were observed for both the 2 DR (92% vs. 68%, P>0.1) and 0 DR groups (59% vs. 40%, P>0.3) these differences were not significant. Stratifying the data for transfusion status revealed that the positive influence of HLA A and B matching in the 1 DR group was dependent upon the presence of preoperative blood administration. Graft survival of 87% for the PRE transfused recipients of grafts matched for ≥2 A and B antigens was significantly better (P<0.001) than the 42% survival observed in similarly transfused recipients of poorer matched organs. Conversely, A and B matching was not significantly beneficial in the 1 DR recipients transfused only at the time of transplant with graft survivals of 57% vs. 43% for those matched for ≥2 or < 2 A and B antigens, respectively (P>0.3). This analysis suggests that a combined effect of both HLA A and B matching and preoperative blood transfusions may allow for highly successful first cadaver renal transplantation in the face of DR incompatibility.

Bowel-Drained Pancreas Transplants

Insulin-dependent diabetes mellitus ranks as one of the major disease entities in the world. Six hundred thousand new patients are diagnosed each year in the United States. Prior to the introduction of insulin, the life expectancy of diabetic patients was about two years from the time of diagnosis. In spite of insulin therapy, the morbidity resulting from microangiopathy still exists. The National Commission on Diabetes in the United States has reported that insulin-dependent diabetes mellitus patients are 25 times more prone to blindness, 17 times more prone to renal disease, five times more afflicted with gangrene, and twice as often exposed to heart disease and stroke than nondiabetic individuals. Diabetes mellitus is the cause of 260,000 deaths annually and has a health care cost of

Optimal preservation of cadaver kidneys with aortic perfusion

18 billion.