R.M.R. Taylor

Urological complications following renal transplantation

A total of 1016 consecutive renal transplants performed between 1976 and 1990 were analysed retrospectively to determine the incidence of urological complìcations and possible predisposing factors. Some 189 episodes of ureteric obstruction and/or urinary leak occurred in 143 patients (overall incidence 14.1 %). The median annual rate of urinary leak was 5.1%; that of ureteric obstruction was 4.5% pre-1986 and 16.1% post-1986. Sixty-three episodes of urinary leak occurred in 54 patients from 1 day to 3 months post-transplant and 60% involved the distal ureter. Thirty were treated primarily by reconstructive surgery, ten required nephrectomy and three died of associated sepsis. A total of 126 episodes of ureteric obstruction occurred in 104 patients from 1 day to 12 years post-transplant and 86% involved the distal ureter. Prior to 1986, 10/11 patients with ureteric obstruction were treated by reconstructive surgery, but since then 88 (95%) have been treated by percutaneous nephrostomy, with or without stenting, with only one graft lost and no deaths. Children had a significantly increased incidence of ureteric obstruction (P<0.001) whilst male recipients had an increased incidence of urinary leak (P=0.04). More patients with ureteric obstruction than those without had two or more episodes of rejection (P=0.03). No single cause for the increased incidence of ureteric obstruction since 1986 has been identified. Continued attention to technical detail and further study of this trend is warranted.

Immunosuppression With Polyunsaturated Fatty Acids In Renal Transplantation

A double-blind controlled trial has been undertaken to assess the value of a preparation containing polyunsaturated fatty acids (PUFA) in human cadaveric renal transplantation. Eighty-nine patients were studied and followed for 6 months after transplantation. Forty-four took the PUFA preparation and 45 the placebo (oleic acid). Other immuno-suppression was standardised. Functional graft survival was significantly better in the PUFA group than in those taking the placebo during the first 3 to 4 months post-transplant. At 6 months, however, although the difference between the groups persisted, it was no longer statistically significant. Complications were equally distributed between the groups.

Administration of ATG according to the absolute T lymphocyte count during therapy for steroid-resistant rejection

Abstract. In renal transplantation, treatment of steroid‐resistant rejection (SRR) with antithymocyte globulin (ATG) has been widely reported but over‐immunosup‐pression remains a common problem. In the first ten patients (group 1) treated for SRR with rabbit ATG, three developed serious viral infections and two deaths occurred due to CMV pneumonitis. ATG was only omitted if thrombocytopenia or neutropenia occurred. In the next 17 patients (group 2) with SRR, ATG was administered according to the absolute T lymphocyte count. T lymphocytes were measured by flow cytometric analysis of CD3‐labelled lymphocytes. ATG dosage was adjusted on a daily basis to keep the absolute T lymphocyte count under 50 cells/μl. Administration of ATG according to the absolute T lymphocyte count resulted in a significant reduction in the mean dose of ATG given to the group 2 patients (P < 0·001). A significant decrease in the incidence of serious viral infections (P= 0·04) was achieved without reducing the ability of ATG to reverse the SRR (P= 0·29) or increasing the number of grafts lost at 1 year in the group 2 patients (P= 0·23).

Evaluation of new perfusion solution for kidney preservation.

We have compared the physical and biochemical properties of plasma and plasma protein fraction (PPF). We have found PPF to be a very satisfactory physiological hepatitis-free plasma substitute. Using PPF as a perfusion solution, we have preserved kidneys for 24 hr after up to 40 min of warm ischaemia and obtained immediate return of function on reimplantation. Perfusion with potassium-enriched plasma protein fraction (PPF2) prevented potassium leakage from the renal cells. Using PPF, we have avoided prefiltration, and we have been able to use a very simple and inexpensive perfusion apparatus.

ASSESSMENT OF CADAVERIC KIDNEYS FOR TRANSPLANTATION

Abstract Many cadaver kidneys transplanted in Britain never function; others function only after a delay, and the long-term prognosis for these kidneys is very poor. By carrying out continuous hypothermic perfusion of the kidneys before transplantation some of those which will never function can be identified and their transplantation may be avoided. By measuring the level of lactate in the perfusates of the remainder, the kidneys which will function immediately and those which will not can be predicted. It is suggested that, if cadaver kidneys become more plentiful, transplantation of the latter group of kidneys may be avoided.

RENAL ALLOGRAFT REJECTION : POSSIBLE INVOLVEMENT OF ANTIBODY-DEPENDENT CELL-MEDIATED CYTOTOXICITY

We have demonstrated that serum from appropriately sensitized patients can contain IgG antibodies that bind to cultured renal epithelial cells. The presence of such antibodies on the surface of renal cells enables otherwise nonlytic PBMC to lyse these renal cells by an antibody-dependent cell-mediated cytotoxicity (ADCC) mechanism. Experiments involving cell-sorting and specific complement-mediated lysis showed that the ADCC effector cells were of the CD3 -ve, C16 +ve phenotype characteristic of NK cells. In this report it is argued that an ADCC mechanism may be of importance in mediating chronic renal cell damage in the absence of acute allograft rejection.

RENAL TRANSPLANTATION IN THE UNITED KINGDOM AND IRELAND—THE CENTRE EFFECT

A detailed audit was done of eight of the twenty-nine transplant centres serving the UK and Ireland. These 8 centres account for one-third of the total renal transplant operations in these two countries. Information was obtained from each centre by means of a comprehensive questionnaire, a 1 1/2 day visit by the three authors, and an analysis of 50 consecutive first cadaver transplants. The 8 centres were chosen in the knowledge that 4 had high and 4 had low 3-month graft-survival rates. Our audit confirmed a centre effect, with a range in 1-year patient survival of from 82% to 96% and of first cadaver graft survival of from 54% to 82%. The two main factors affecting success rate were the rate of irreversible acute rejection and death with a functioning kidney. Our investigations suggested that the centre variation in acute rejection was influenced by blood transfusion and the variation in mortality by steroid dose and recipient age. Careful and well-organised clinical management cannot be easily quantified but was thought to have an important influence. Widespread adoption of pre-transplant blood transfusion and increasing use of cyclosporin will probably contribute to the further lessening of the centre effect which has already been observed over the past few years.

Continuous ambulatory peritoneal dialysis and renal transplantation: a five year experience.

Continuous ambulatory peritoneal dialysis is a new and increasingly popular method of routine dialysis, but its effect on renal transplantation is uncertain. A non-randomised comparison was made of the outcome of grafting in patients who had been treated before transplantation with continuous ambulatory peritoneal dialysis with that in patients treated with haemodialysis. During the five years, 1979-84, after continuous ambulatory peritoneal dialysis was introduced to Newcastle upon Tyne 220 patients have received transplants after either continuous ambulatory peritoneal dialysis (61 patients) or haemodialysis (159 patients). During follow up no significant differences occurred in survival of patients or grafts between the two treatment groups. One year after transplantation the percentages of survivors who had received continuous ambulatory peritoneal dialysis and haemodialysis were 88% and 91% respectively, and overall graft survival was 66% and 72%, respectively. A multiple regression model was used to allow for differences among patients--for example, duration of dialysis and number of preoperative transfusions--on the survival of grafts. When only first cadaver grafts were considered (in 152 patients) graft survival (non-immunological failures excluded) was not significantly different between the patients treated with continuous ambulatory peritoneal dialysis and haemodialysis. Continuous ambulatory peritoneal dialysis is not a risk factor in renal transplantation, and its continued use in treatment of potential renal graft recipients is recommended.

Significance of Perfusate Lactic Acidosis in Cadaveric Renal Transplantation

Thirty-two human cadaver kidneys were assessed by continuous perfusion before transplantation. Altogether, 26 were transplanted. Ten kidneys functioned immediately, of which nine had excellent renal function at three months. Sixteen had delayed onset of function, of these only five had excellent function at three months. There was no difference in warm ischaemic interval between the two groups or in ice storage time. The immediate function group, however, were perfused for twice as long as the delayed function group. The two groups could not be separated on donor history, but they could be precisely separated during perfusion by measuring lactic acidosis and lactic acid dehydrogenase (LDH). The biggest single difference between the groups was in terms of donor preparation.

Relation of immediate post-transplant renal function to long-term function in cadaver kidney recipients.

Renal function studies 12 to 41 months after transplantation have been performed on seven cadaver renal allograft recipients who demonstrated immediate primary function after transplant (group A) and seven similar recipients who had delayed primary function (group B). The groups were matched as closely as possible for major physical characteristics and their postoperative management; in particular, only one patient had a post-transplant renal biopsy. Glomerular filtration rate determined by 24-hr creatinine clearance, endogenous creatinine clearance, and inulin clearance was usually lower in those patients having delayed primary function and they excreted more glucose per 24 hr and reabsorbed a smaller proportion of the filtered glucose load under infusion conditions. These results are discussed in relation to the effect of immediate and delayed primary function on the long-term prognosis of such patients.