Donald Steinmuller

Long-Term Follow-up after Partial Removal of a Solitary Kidney

BACKGROUNDnThe removal of more than one kidney in animals leads to proteinuria and progressive renal failure due to focal segmental glomerulosclerosis. This injury may be the result of chronic glomerular hyperfiltration. The purpose of this study was to determine the effect of a reduction in renal mass of more than 50 percent on residual renal function and morphology in humans.nnnMETHODSnWe evaluated long-term renal function in 14 patients with a solitary kidney who had undergone partial nephrectomy for renal-cell or transitional-cell carcinoma. In 12, the first kidney had been removed 2 months to 21 years previously for the same type of cancer; in 2, the other kidney was congenitally atrophic. Before surgery, no patient had clinical or histopathological evidence of primary renal disease. All 14 patients underwent partial nephrectomy to remove a localized tumor, with 25 to 75 percent of the solitary kidney being excised. They were evaluated 5 to 17 years after surgery (mean, 7.7).nnnRESULTSnTwelve patients had stable postoperative renal function, and end-stage renal failure developed in two. There were no changes in blood pressure in any patient during follow-up. Nine patients had proteinuria, which was mild (0.15 to 0.8 g of urinary protein per day) in five. The extent of proteinuria was inversely correlated with the amount of remaining renal tissue (P = 0.0065) and directly correlated with the duration of follow-up (P = 0.0005). Four patients with moderate-to-severe proteinuria had renal biopsies, which revealed focal segmental glomerulosclerosis in three patients and global glomerulosclerosis in one.nnnCONCLUSIONSnLong-term renal function remains stable in most patients with a reduction in renal mass of more than 50 percent. These patients are, however, at increased risk for proteinuria, glomerulopathy, and progressive renal failure.

Ineffectiveness of dipyridamole spect thallium imaging as a screening technique for coronary artery disease in patients with end-stage renal failure

The efficacy of dipyridamole single photon emission computed tomography (SPECT) thallium as a screening test for coronary artery disease (CAD), was studied in 45 patients with end-stage renal failure undergoing evaluation for renal transplantation. Coronary arteriography, dipyridamole SPECT thallium imaging and clinical follow-up were performed in all patients. Nineteen patients (42%) had an obstruction of 50% or more in at least one coronary artery. Fourteen patients had a positive thallium scan, but 7 of these were false-positives (sensitivity 37%, specificity 73%). The sensitivity was considerably lower than that quoted for non-ESRF patients in the literature, and significantly lower than a control group of 19 patients without ESRF having comparable severity and distribution of CAD. Five of the 6 patients who died of cardiac causes over a mean follow-up period of 25 months had normal thallium imaging, but all had significant coronary artery disease at cardiac catheterization. Dipyridamole SPECT thallium imaging has not proved a useful screening test for angiographically significant CAD, and does not predict cardiac prognosis in this population.

The use of single pediatric cadaver kidneys for transplantation.

We have reviewed our experience with 126 single pediatric cadaver kidneys (donor ages 9 months to 16 years) transplanted over a 10-year period. There were 17 donors aged 0-2 years, 55 donors aged 0-6 years, 34 donors aged 7-12 years, and 37 donors aged 13-16 years. One-year patient and graft survival was 88.2%/76.5%, 91%/74%,88.3%/69.1%, and 94.4%/80.6% for the respective groups. One-year patient and graft survival for an adult donor control group was 93%/69%. The percentage of recipients requiring dialysis in the early posttransplant period was 70.6%, 54.5%, 52.9%, 51.4%, and 52.4% for all groups, respectively. The time to reach a nadir creatinine was similar in all groups (24-30 days). While the functional outcome was comparable to cadaver transplantation utilizing adult donor kidneys, a higher incidence of infections and technical complications were encountered in the young-donor-age groups. Overall, there were 12 ureteral complications (8 fistulas, 4 stenoses), 3 bladder fistulas, and 4 renal artery stenoses. The urologic complication rate in kidneys from donors 0-2 years of age was 23.5% (all ureteral fistulas) versus 5% in the kidneys from adult donors. Only one graft was lost due to a technical complication. We conclude that, while cadaver kidneys from donors in the young age groups may be utilized successfully for transplantation, a higher incidence of urologic complications may be associated with their use. Careful harvesting and intraoperative techniques may minimize complications when utilizing kidneys from these donors.

Detrimental effect of cyclosporine on initial function of cadaver renal allografts following extended preservation. Results of a randomized prospective study.

We report herein the resul6ts of a randomized prospective trial comparing maintenance cyclosporine (CsA)-p prednisone immunosuppression to a regiment of aazathioprine-prednisone-antilymphocyte globulin (ALG) in cadaver renal transplant recipients. Fifty-six patients were entered into this study with 31 assigned to the ALG group and 25 to the CsA group. These two groups were well matched for most major determinants of graft outcome and the mean renal preservation time was 37 hr in each group. The incidence of acute tubular necrosis (ATN) was high in both groups (58% ALG, 72% CsA, NS). There were five cases of primary nonfunction in the CsA group and only one in the ALG group (P=.05). Of the kidneys that functioned, the mean seum creatimine nadir (1.5 vs. 2.2 mg/dl, P=.03) were both loss in the ALG group. The actuarial one-year graft survival rate in the ALG and CsA groups is 78% and 48%, respectively (P<.05). This difference is mainly due to the large number of primary nonfunctioning grafts in the latter group, which we attribute to the effect of CsAs nephrotoxicity superimposed on renal ischemia incurred prior to transplantation. These data emphasize that, in order to realize the full benefit of csA in cadaver transplantation, renewed emphasis must be placed on minimizing ischemic renal damage.

The development of proteinuria and focal-segmental glomerulosclerosis in recipients of pediatric donor kidneys.

Several reports in animals, and sporadic case reports in humans, have suggested that kidneys with decreased nephron mass may be more susceptible to the development of focal-segmental glomerosclerosis. This prompted a reexamination of our previously reported group of pediatric donor-adult recipient renal transplant combinations. Data were analyzed from 31 adult recipients who had received renal transplants from cadaver pediatric donors (<6 years) with graft function for >6 months and no evidence of chronic rejection. These were compared with a control group transplanted during the same period with adult donor kidneys. Immunosuppression consisted of azathioprine/prednisone or quadruple therapy in 16 and 15 patients respectively. End-stage renal disease (ESRD) was secondary to chronic glomerulonephritis (n=9), diabetes mellitus (n=6), polycystic kidney disease (n=5), and miscellaneous causes (n=ll). Twenty patients had radiographic documentation of renal hypertrophy posttransplant. All patients had serial 24-hr urinalysis for protein and creatinine after transplantation during periods of stable renal function. Ten patients had renal biopsies performed at a mean time from transplant to biopsy of 10.4±1.6 months. Seven recipients had biopsies that revealed glomerulosclerosis at 13±6 months posttransplant. Protein excretion and serum creatinine in these patients were significantly higher than in control patients (1.6±0.37 vs. 0.49+0.15 g/24 hr and 1.96±0.11 vs. 1.64±0.09 mg%; P<0.03 and P<0.01, respectively). Only 3 of 25 control adult donor recipients developed proteinuria > 0.8 g/24 hr within 2 years of transplantation vs. 15/31 pediatric donor recipients. No correlations with the etiology of ESRD, age (>or< 40 years), weight, sex, diabetes, hypertension, or the number of acute rejection episodes could be found. Our data suggest that adult recipients of pediatric donor renal transplants may be at greater risk for the development of glomerulosclerosis than those recipients receiving adult donor kidneys.

Long-term efficacy of ureteral dilation for transplant ureteral stenosis

Transluminal ureteral dilation was performed in 11 renal allograft recipients with transplant ureteral obstruction. Success was achieved in 5 patients (45 per cent) with a followup of 12 to 29 months (mean 19.6 months). All failures have been evident within 12 months of dilation. We conclude that ureteral dilation can provide long-term success in renal allograft recipients. However, continued close long-term monitoring of the anatomical and functional result is mandatory for patients treated in this manner.

Pretransplant assessment of renal viability by phosphorus-31 magnetic resonance spectroscopy. Clinical experience in 40 recipient patients.

A group of 40 cadaveric kidneys was studied just prior to planned transplantation to further assess the applicability of 31P-MRS in the analysis of clinical renal transplant viability. Renal intracellular high-energy phosphorus metabolites (ATP [or NADP], phosphomonoester [PME] and inorganic phosphate [Pi]) and pH were measured noninvasively with MRS surface coils external to cold storage containers. Pretransplant MRS parameters were correlated with subsequent renal function in recipient patients (measured one week postoperatively by the need of dialysis, drop in serum creatinine, urine output, and 123I or 131I Hippuran assessed renal tubular function). ATP and NADP was detected in eleven kidneys and was significantly (P<0.001) associated with the best renal function posttransplantation. These kidneys also had the highest PME/Pi ratios (1.66–0.54), while lower ratios (0.36–0.10) were associated with prolonged acute tubular necrosis. The PME/Pi ratios significantly (P<0.0001) correlated with subsequent clinical renal function, whereas cold storage times (37±10 hr) or intracellular renal pH (6.53–7.91) did not. These preliminary data suggest that MRS is a noninvasive, nondestructive and sterile method for assessing clinical viability during hypothermic storage of human cadaver kidneys and the subsequent recovery of renal function postrenal transplantation.

Sexuality, fertility, and renal transplantation: A survey of survivors

A questionnaire on sexual function and fertility was completed by 54 men and 36 women, at an average of 3 years after successful renal transplant. Sexual desire increased significantly compared to reports of levels 6 months pretransplant. Men also had improved erectile function and ability to reach noncoital orgasms. About a quarter of men and women remained sexually dysfunctional, however. The frequency of sexual activity and overall sexual satisfaction did not improve significantly. Marital status and satisfaction were in the normal range for this group, except that those who became ill before adulthood were less likely to have married or have had children. Infertility was a major concern for 10% of the sample. Regular menstrual cycles were present in 64% of women under age 50, representing a significant improvement after transplantation. Three men fathered a child and two women became pregnant after transplantation. Most patients wanted more information on sexuality, fertility, and renal disease.

A critical look at survival of diabetics with end-stage renal disease. Transplantation versus dialysis therapy.

The survival of 100 consecutive patients with diabetic nephropathy after treatment with hemodialysis, peritoneal dialysis, or renal transplantation was reviewed at our institution from 1976 to 1982. Standard actuarial survival analysis revealed an overall survival of 83% and 61% at one and two years, respectively. Coronary angiography was used as a screening procedure for renal transplantation. In the dialysis group, 27 patients were considered acceptable transplant candidates on the basis of the coronary angiography but were not transplanted for other reasons. When the survival analysis was limited to those transplant candidates the survival rates were 78%, 51%, and 8% at 1, 2, and 5 years, respectively. In comparison, survival after transplantation was 81%, 67%, and 45%, at 1, 2, and 5 years, respectively. In order to eliminate bias, survival comparisons were subsequently made using the Cox Proportional Hazard Model to take into account the time the transplant patients spent on dialysis prior to renal transplantation. When this analysis was performed, there was no significant difference in survival between transplantation and dialysis for the first two years, but overall survival after five years was significantly better after renal transplantation even when the comparison was limited to acceptable transplant candidates who remained on dialysis (P = .04). Survival for patients with significant coronary disease (greater than 70% stenosis of a coronary vessel or moderate to severe left ventricular dysfunction) was analyzed according to therapeutic modality. Although overall prognosis was poor in this group as a whole (1, 2, and 5 year survivals were 76%, 45%, and 19%, respectively), the cardiac patients had a trend to better survival after renal transplantation than when maintained on dialysis (P = .22). In addition to other factors such as quality of life, rehabilitation, and progression of other diabetic complications, the benefit of renal transplantation on patient survival must be considered when deciding between renal transplantation and maintenance dialysis therapy for diabetic patients with renal failure.

Flank Donor Nephrectomy: Efficacy in the Donor and Recipient

Since August 1983, 115 patients have undergone live donor nephrectomy via an extraperitoneal flank approach with rib resection. Over-all hospital stay was short and morbidity was negligible. Early graft function was excellent as determined by urinary output in the first 20 hours postoperatively (mean 6,442 cc) and low nadir serum creatinine (mean 1.57 mg. per dl.). Acute tubular necrosis or urinary fistula developed in 3 kidneys (2.6 per cent). In the entire series, only 1 graft (0.8 per cent) was lost to technical complications. We conclude that an extraperitoneal flank approach to live donor nephrectomy is safe for the donor, and provides a structurally and functionally sound allograft for the recipient.