P.J. Morris

LEGIONNAIRES' DISEASE IN A TRANSPLANT UNIT: ISOLATION OF THE CAUSATIVE AGENT FROM SHOWER BATHS

Legionnaires disease was diagnosed in two patients in a transplant unit, both patients having occupied the same postoperative cubicle shortly before onset of their illnesses. Legionella pneumophila was found in water taken from the cubicle shower bath and from other showers in the unit. To eradicate the legionellae, the water supply was treated with chlorine, but this had only a temporary effect.

MATCHING FOR B-CELL ANTIGENS OF THE HLA-DR SERIES IN CADAVER RENAL TRANSPLANTATION

Stored and fresh lymphocytes from 84 donors and recipients of cadaveric renal allografts have been retrospectively typed for 7 HLA-DR antigens. The match between donor and recipient was graded as 2, 1, or 0 identities. Graft function was assessed by (i) failure or success at 3 months, (ii) serum-creatinine at 3 and 6 months, and (iii) the number of rejection episodes occurring within 3 months. All 4 recipients with 2 identities had good 3-month function, and all are still functioning at 5--19 months. Recipients with 1 identity had both a higher success-rate and better quality of function than those with 0 identities. Although the differences do not reach significance, a continuing prospective study of HLA-DR matching is justified, with particular emphasis on performing transplants where two DR antigens are shared between donor and recipient.

Oral versus intravenous high-dose steroid treatment of renal allograft rejection. The big shot or not?

50 episodes of renal allograft rejection were treated by oral prednisolone and 49 by intravenous methylprednisolone. Both treatments achieved reversal of rejection in approximately 60% of episodes. Morbidity-rates, as assessed by hypertension, oliguria, fluid retention, and infection, tended to be greater after oral treatment. When the results were reexamined for accelerated, acute, and chronic rejection episodes the only difference demonstrated was an increased frequency of fluid retention in patients treated by oral prednisolone for an acute rejection episode. There was no evidence that intravenous methylprednisolone was nephrotoxic.

LOCALISATION OF INSULINOMAS

Small insulinomas may be undetectable by arteriography or palpation of the pancreas. They can be identified, however, by the point at which high insulin levels are detected in the venous effluent sampled at several sites by catheterisation of the splenic and portal veins at laparotomy or via the percutaneous transhepatic route. Diagnosis by catheterisation techniques made it possible to resect only that part of the pancreas containing the tumour (in one patient the head and in another the body of the pancreas). Improved localisation is essential in planning an operation, and often removes the need for lengthy trials of medical therapy before laparotomy.

CORRELATION OF HLA AND THYROID ANTIBODIES WITH CLINICAL COURSE OF THYROTOXICOSIS TREATED WITH ANTITHYROID DRUGS

The prevalence of HLA-B8 in thyrotoxic (Graves disease) patients who relapsed after withdrawal of antithyroid drugs was high (69%) compared with that in patients who remained in remission (40%) and in healthy controls (28%). B8-positive patients were 1-8 times more likely to relapse after withdrawal of drug therapy than B8-negative patients. The persistence of thyroid microsomal antibodies after withdrawal of therapy correlated significantly with the presence of HLA-B8. This association was more pronounced in patients who remained in remission. From this it might be assumed that B8 is also associated with the persistence of thyroid T.S.H. (thyroid-stimulating hormone) receptor stimulating antibodies. In view of these findings, it is suggested that patients who are thyrotoxic might be typed for HLA, and those who are B8-negative could be given a trial of long-term antithyroid drug therapy.

RENAL TRANSPLANTATION AND B-CELL CROSS-MATCHES WITH AUTOANTIBODIES AND ALLOANTIBODIES

Of 51 cadaveric kidneys transplanted between June, 1976, and June, 1977, 18 were transplanted in the presence of a positive cross-match against the donors B lymphocytes. 11 of these positive cross-matches were due to alloantibodies and 7 due to autoantibodies. Autoantibodies were defined not only on the basis of autoreactivity with B lymphocytes but also by their absent or restricted reactivity with lymphocytes from patients with chronic lymphocytic leukaemia. Transplants in 8 of 11 patients with a positive alloantibody-B-cell cross-match and in 6 of 7 patients with a positive autoantibody-B-cell cross-match were successful at 3 months. These success-rates were no different from those found in patients with a negative B-cell cross-match. Thus, renal allografts may be performed with a reasonable assurance of success in the presence of a positive B-cell cross-match whether due to autoantibodies or to alloantibodies.

RESULTS FROM A NEW RENAL TRANSPLANTATION UNIT

158 kidneys, 9 from living related donors and 149 from cadavers, have been transplanted in the first 42 months of the establishment of a transplant unit at Oxford. Patients ages ranged from 11 to 56 (mean 35) years. Azathioprine and prednisolone alone were used for immunosuppression, and a minimum-transfusion policy was in operation throughout. After cadaveric transplantation actuarial patient-survival is 70% and 68%, respectively, at the same intervals. 85% of patients who had a functioning graft are fully rehabilitated. Matching for HLA-DR, pregraft blood-transfusions, and the finding that a transplant could be performed in the presence of a positive B-cell crossmatch have proved to be the most significant of the many factors examined both prospectively and retrospectively. The function of the unit is based on dialysis and transplantation for all patients in end-stage renal failure, with transplantation being considered the first line of treatment for patients under the age of 56. The results of transplantation reported here, which have been achieved with conventional immunosuppressive therapy and minimum-transfusion policy, might be considered a standard against which modifications of the practice of renal transplantation can be compared.

RENAL TRANSPLANTATION AND A POSITIVE SEROLOGICAL CROSS-MATCH

A renal transplant involving a recipient with a positive serological cross-match against donor lymphocytes generally results in hyperacute rejection of the graft. 13 cadaveric renal transplants were performed in recipients with a known positive serologic cross-match against donor B lymphocytes. 12 of these serological cross-matches were positive against donor blood, node, or spleen lymphocytes, but the reactivity was directed against donor B lymphocytes only. 3 transplants failed, 2 because of rejection and 1 because of renal-artery thrombosis. 10 transplants are functioning, 6 to 42 weeks after the operation. Of these 10 successful grafts, 3 had no acute rejection episodes, while 7 had an early acute rejection episode which responded to treatment. Histologically, the grafts showed a cellular rejection, similar to that in enhanced renal allografts in the rat. It is possible to transplant a kidney in a high-risk patient with a positive B lymphocyte cross-match with a low risk of failure. In addition active enhancement of the graft might sometimes occur.

Control of hypertension after renal transplantation by embolisation of host kidneys.

A percutaneous embolisation technique was used for host kidney ablation in 13 patients with renal allografts and hypertension. Markedly improved blood pressure control was achieved in 9 of them, and morbidity was minimal. All patients have been followed from 12 to 25 months. Embolisation of the host kidneys appears to be a simple, effective, and less hazardous alternative to surgery in the treatment of drug-resistant hypertension after renal transplantation in some patients.

Reprinted Article “Exercise Training Versus Angioplasty for Stable Claudication. Long and Medium Term Results of a Prospective, Randomised Trial” ☆ ☆☆

OBJECTIVESnTo compare percutaneous transluminal angioplsty (PTA) against exercise training in the treatment of stable claudication.nnnDESIGNnProspective, randomised trial.nnnMATERIALSnFifty-six patients with unilateral, stable, lower limb claudication assessed prior to randomisation, at 3 monthly intervals for 15 months, and at approximately 6 years follow-up. Thirty-seven patients were available for long term review.nnnOUTCOME MEASURESnAnkle/brachial pressure index (ABPI), treadmill claudication and maximum walking distances, percentage fall in ankle systolic pressure after exercise.nnnRESULTSnSignificant increases were seen in ABPI in the patients treated with PTA at all assessment to 15 months. However in terms of improved walking performance, the most significant changes in claudication and maximum walking distance were seen in the exercise training group. At long term follow-up, there was no significant difference between the groups. Subgroup analysis by angiographic site of disease showed greater functional improvement in those patients with disease confined to the superficial femoral artery treated by exercise training. The overall prognosis for the whole group of patients was benign, with only two (4%) undergoing amputation.nnnCONCLUSIONSnExercise training confers a greater improvement in claudication and maximum walking distance than PTA, especially in patients with disease confined to the superficial femoral artery.