John P. Merrill

Successful Homotransplantation of the Human Kidney Between Identical Twins

○ A patient whose illness had begun with edema and hypertension was found to have suffered extreme atrophy of both kidneys. Because of the steady worsening of the condition and the appearance of uremia with other unfavorable prognostic signs, transplantation of one kidney from the patients healthy identical twin brother was undertaken. Preparations included collection of evidence of monozygosity and experimental transplantation of a skin graft from the twin. During the transfer of the healthy kidney it was totally ischemic for 82 minutes. Evidence of functional activity in the transplanted kidney was obtained. The hypertension persisted until the patients diseased kidneys were both removed. The homograft has survived for 11 months, and the marked clinical improvement in the patient has included disappearance of the signs of malignant hypertension.

Renal failure in the patient with cirrhosis: The role of active vasoconstriction

Renal hemodynamics were studied with the 133 Xe washout technic and renal arteriography in fifteen patients with cirrhosis and varying degrees of renal functional impairment. In cirrhotic patients with renal failure extreme hemodynamic instability was encountered, characterized by variability and irregularity of xenon washout, in contrast to patients with renal failure of other etiology. Marked instability was more frequent in cirrhotic patients with azotemia, and was so severe in three instances that the curves were unanalyzable. The remaining curves revealed a decrease in both mean renal blood flow and the percentage of flow in the rapid flow component in approximate proportion to the decrease in creatinine clearance, suggesting a reduction in cortical perfusion. The arteriographic findings, including the absence of a cortical nephrogram and unrecognizable renal cortical vasculature in the patients with the most severe degree of renal failure, support the concept of a reduction in renal cortical perfusion. The finding of marked hemodynamic instability strongly suggests that the renal ischemia is secondary to active vasoconstriction. Consistent reversal of all the vascular abnormalities in the kidneys of five cirrhotic patients at postmortem angiography provides further evidence for the functional basis of the renal failure, operating through active renal vasoconstriction. Phentolamine infusion into the renal artery in four patients did not significantly alter renal hemodynamics indicating that increased sympathetic nervous system activity was not responsible for the active vasoconstriction and cortical ischemia.

Senescence and the Renal Vasculature in Normal Man

The xenon washout technique and the renal blood flow response to vasoactive agents or alterations in sodium intake were used to characterize the effect of aging on the renal vasculature in 207 normal human subjects ranging in age from 17 to 76 years. A highly significant, progressive reduction in the mean blood flow, the rapid-component flow rate, and the percent of flow into the rapid-flow (cortical) compartment accompanied advancing age. Because 133Xe measures flow per unit tissue mass, the results indicated a larger reduction in flow than in mass—the anticipated finding if flow reduction is primary in the genesis of atrophy. Age also reduced the vasodilation consequent to administration of acetylcholine or a sodium load; this finding is consistent with a fixed lesion of the vessels. Responses to angiotensin were not modified by age. Thus, offsetting factors of increased ratio of wall to lumen thickness and smooth muscle atrophy are precisely matched. The findings in this study agree with earlier hypotheses based on morphology that suggest a primary vascular process in the development of age-related renal changes.

Kidney transplantation between seven pairs of identical twins.

Kidney Transplantation Between Seven Pairs of Identical Twins JOSEPH MURRAY;JOHN MERRILL;J. HARRISON; Annals of Surgery

Kidney Transplantation in Modified Recipients

Kidney Transplantation in Modified Recipients Joseph Murray;John Merrill;Gustave Dammin;James Dealy;Guy Alexandre;J. Harrison; Annals of Surgery

Survival of Patients Undergoing Chronic Hemodialysis and Renal Transplantation

Abstract Over an eight-year period 172 patients received an allograft from a living, related donor, 112 received cadaveric transplants, and 125 were placed on home dialysis. In a period of three years, 287 patients passed through our center dialysis program. Analysis of survival curves shows that patient survival was significantly better in recipients of transplants from living, related donors and in dialysis patients than in those receiving a cadaver graft. One-year patient survival rates for recipients of parental, sibling and cadaver allografts were 84.2, 89.5 and 68.7 per cent respectively. Survival rates at one and two years for home-dialysis patients were 88.5 and 77.8 per cent, and similar values for center patients were 92.9 and 86.1 per cent. These probabilities should be considered in the choice of which form of therapy to employ in a given patient, and illustrate the need for continued investigation into the prevention of allograft rejection and cadaver-recipient selection, (N Engl J Med 288:86...

Cardiovascular Disease in Dialysis Patients

During the past several years evidence has been accumulating that cardiovascular disease is the leading cause of death among patients undergoing chronic hemodialysis therapy. Between 40 and 60 per ...

Immunologic Rejection of Human Cancer Transplanted with a Renal Allograft

Abstract Metastatic carcinoma of the bronchus, inadvertently transferred to a patient when a kidney was transplanted from a cadaveric source, underwent immunologic rejection in the new host. This metastatic focus in and around the transplanted kidney did not appear until 18 months after the allograft was placed. When immunosuppressive therapy was discontinued, the previously functioning kidney was promptly rejected whereas tumor growth did not appear to be altered. After removal of the kidney, however, the residual cancer disappeared. The patient received a second kidney transplant nine months after removal of the first. There has been no evidence of further metastatic cancer despite resumption of a full program of immunosuppression.

Disappearance of Uremic Itching after Subtotal Parathyroidectomy

ALTHOUGH many uremic symptoms can be improved or prevented by adequate dialysis1 others, including anemia, peripheral neuropathy, secondary hyperparathyroidism and hypertension, to name only a few,...

Factors contributing to the declining mortality rate in renal transplantation.

Recent modifications and refinements in the management of patients with renal allografts have diminished the mortality rate at our hospital to 2 per cent and 5 per cent at one year for patients receiving kidneys from related and cadaveric sources, respectively. Of 186 receiving transplants since 1974, seven (4 per cent) have died within one year of operation. The incidence of wound infections has been reduced from approximately 25 per cent in 1972 to 2 per cent since 1976 by the use of a single high dose of broad-spectrum antibiotics administered at the time of induction of anesthesia for any surgical procedure. Risk and limitations of immunosuppression have been better appreciated, ultrasound is used more often in the diagnosis of partial obstruction or perinephric fluid collections, and needle biopsy of the transplanted kidney has reduced the morbidity inherent in open biopsy. The contribution of sepsis as a cause of death has declined. The diminishing hazard of renal transplantation has made it an increasingly attractive treatment for end-stage kidney disease.