Magnus O. Magnusson

Vascular complications of renal transplantation

From January, 1963, to May, 1979, 600 renal transplants were performed at the Cleveland Clinic. There were 21 vascular complications in this series (3.5%). Arterial complications included renal artery thrombosis in 5 patients, renal artery stenosis in 9 patients, and anastomotic hemorrhage in 2 patients. Venous complications included renal vein thrombosis in 2 patients and hemorrhage in 3 patients. Although vascular complications led directly to graft loss in 10 patients, only 1 resulted in patient death.

Mortality and morbidity in pretransplant bilateral nephrectomy Analysis of 305 cases

The surgical riks were analyzed in 305 patients with end stage renal failure who underwent bilateral nephrectomy through midabdominal approach in preparation for kidney transplantation. The over-all mortality rate was 3.6 per cent. Age was the most significant risk factor in the mortality. Patients less than fifty years of age had an operative mortality rate of 3.1 per cent while those more than fifty years had an operative mortality of 11.1 per cent. Other pertinent risk factors were preoperative complications of renal failure and additional surgical procedures at the time of bilateral nephrectomy. The leading causes of death were those of cardiovascular complications and infection. The morbidity rate was 58.7 per cent being major in 18 per cent and minor in 40.7 per cent. Bilateral nephrectomy is recommended selectively in patients with (1) chronic pyelonephritis with urinary tract infection, (2) major vesicoureteral reflux, (3) immunologically active glomerulonephritis, (4) severe hypertension uncontrollable by adequate dialysis, and (5) extremely large or infected polycystic kidneys.

Multiple-Artery Renal Transplantation: Emphasis on Extracorporeal Methods of Donor Arterial Reconstruction

The operative techniques to transplant kidneys with multiple renal arteries and our recent experience with them are reviewed. The preferred methods are anastomosis with a Carrel aortic patch and extracorporeal arterial repair before transplantation. These are simple and effective methods that avoid subjecting the kidney to prolonged ischemia. Revascularization of all renal arteries is important to obviate ischemic allograft complications.

The fate of cadaver renal allografts contaminated before transplantation.

Through the routine use of cultures from saline slush transport solution and the initial and final organ perfusates, 14 of 81 cadaver allografts (17.3%) were found to have been contaminated before transplantation. Gram negative organisms, cultured from 5 of the 14 contaminated allografts, resulted in the recipients death on the first encounter with this problem and the loss of two other allografts. Early antibiotic therapy begun even without evidence of overt infection appeared to prevent any further deaths or graft loss in those whose allografts were contaminated and yielded an overall survival comparable to that of uncontaminated allografts. Without such an approach to the study of perfused cadaver allografts and the management of them when found to be contaminated, this type of infection may go undetected and contribute to allograft and patient loss.

Effects of furosemide versus isolated ultrafiltration on extravascular lung water in oleic acid-induced pulmonary edema

We studied the effects of no treatment, furosemide treatment, and isolated ultrafiltration on extravascular lung water (ETV1.) in mongrel dogs in whom pulmonary edema was induced with oleic acid. In all treatment groups, ETV1. was significantly elevated 90 min after oleic acid infusion. At 270 min, we found no difference between nontreatment and furosemide. There was, however, a significant difference between no treatment and ultrafiltration but not between furosemide and ultrafiltration. In spite of observations which suggest that ultrafiltration is of benefit in reducing ETVL, we could not demonstrate superiority of one therapy over another.

Comparison of renal transplantation and dialysis in rehabilitation of diabetic end-stage renal disease patients

We have reviewed the outcome of replacement therapy for end-stage renal disease (ESRD) in 100 diabetic patients with emphasis on late complications, extrarenal diabetic manifestations, and overall patient rehabilitation. Long-term complications, other than myocardial infarction, were not different after renal transplantation compared with chronic dialysis. Overall rehabilitation was better after renal transplantation compared with chronic dialysis (p less than 0.05). Retinopathy and neuropathy were more stable with renal transplantation and peritoneal dialysis compared with hemodialysis (p less than 0.05). These factors should be considered along with expected patient survival when deciding between different treatment modalities for diabetic ESRD.

Renal Vascular Response to Vasodilators Following Warm Ischemia and Cold Storage Preservation in Dog Kidneys

The purpose of this study was to determine whether warm ischemia (WIT) and cold storage preservation (CSP) impair endothelium-dependent vascular relaxation in the kidney. Twenty-four canine kidneys were harvested, preserved with CSP for 24 or 48 hours, and then perfused with canine blood at 37 C for the determination of glomerular filtration rate (GFR), perfusion flow rate, and renal vascular resistance (RVR). There were four experimental groups: Group I--no WIT followed by 24 hours CSP, Group II--30 minutes WIT followed by 24 hours CSP, Group III--no WIT followed by 48 hours CSP, Group IV--30 minutes WIT followed by 48 hours CSP. Endothelial function in each group was evaluated using acetylcholine (ACh, 1 mg. bolus) as an endothelial dependent vasodilator, and sodium nitroprusside (NP, 10 mg. bolus) as an endothelial independent vasodilator. Glomerular filtration rate was significantly less (P < .05) and RVR was significantly greater (P < .05) for kidneys from Groups II, III and IV compared to group I. The highest RVR was observed in kidneys from Groups II and IV. Nitroprusside administration caused an equivalent reduction in RVR among all four study groups. ACh administration caused a similar reduction in RVR in Groups I and III; however, the change in RVR was significantly less in Groups II and IV (P < .05). We hypothesize that the more severe ischemic insult in the latter groups led to vascular endothelial damage with a consequent loss of ability to secrete endothelium-derived relaxing factor in response to ACh administration.

Renal transplantation: III. Prevention of wound infections

Abstract A protocol specifically designed to prevent wound infections in recipients of renal transplants is presented. Comparative results indicate a decrease in wound infections with this regimen.

Renal transplantation I. Use of donor organs with multiple vessels

Abstract The Cleveland Clinic experience in transplanting 46 kidneys with multiple vessels is reported. Suggested surgical techniques for the vascular anatomosis are recommended and long-term results of function and complications are reported. These kidneys can be safely and effectively used from both related living and cadaver donors.

Histologic, ultrastructural, and immunomicroscopic findings in 96 one hour human renal allograft biopsy specimens. Immunologic and clinical significance.

Predicting the outcome of human renal allografts based on studies of one hour biopsy specimens is still controversial. We have tried to correlate histologic, ultrastructural, and immunofluorescence findings in 96 one hour biopsy specimens with histocompatibility matching, the presence of preformed antibodies, allograft ischemia and preservation times, the donors age, the original renal disease, and allograft source, function, and survival. Ultrastructurally, 22 allografts had fibrin deposits in glomerular loops. There was a significant correlation between this finding and poor allograft function (p < 0.01), cold ischemia time (p < 0.02), and cadaveric allograft source (p < 0.01). Sixteen allografts showed epithelial cell detachment from tubular basement membranes. This finding correlated with cadaveric allograft source (p < 0.01). Many other morphologic changes were evaluated by both light and electron microscopy, but they did not bear any significant relationship to any of the aforementioned clinical parameters. Of 30 biopsy specimens studied by direct immunofluorescence, 11 showed positive findings (immunoglobulins or C3) in either glomeruli, vessels, or both. There was no significant correlation between these findings and the clinical parameters.