Robert C. MacDonell

Living related kidney donors: a 14-year experience

Living related donor (LRD) nephrectomies are controversial due to the risks to the donor and improved cadaveric graft survival using cyclosporine A. Between December 22, 1970, and December 31, 1984, 1096 renal transplants were performed at a single institution, 314 (28.6%) from LRD. The average age was 34.3 years (range: 18-67); none had preoperative hypertension. All nephrectomies were performed transabdominally. Major perioperative complications occurred in 22 (7.0%). These include wound infections (3.5%), pancreatitis (1.0%), injuries to spleen (1.0%) or adrenal gland (0.3%) requiring removal, pneumonitis (0.6%), ulnar nerve palsy (0.6%), femoral artery thrombosis after arteriogram (0.3%), pulmonary embolus (0.3%), and upper pole infarct of contralateral kidney (0.3%). There are six known deaths in this series, none of which were related to the operation. Major late complications were seen in 50 (20.0%) of 250 patients followed for 6 to 175 months (mean 53.1 months). These included definite hypertension (5.6%), suture granuloma (4.4%), incisional hernia (3.6%), proteinuria (2.4%), bowel obstruction (2.0%), nephrolithiasis (1.2%), wound infection (0.4%), scrotal hydrocele (0.4%), and chronic pancreatitis (0.4%). While the risk of hypertension appears to increase as the interval from donation increases, no cases of renal failure after donation have been noted, and negligible proteinuria among those followed long-term has been seen in this series. It is felt that living related kidney donation is justified when the relative is sincerely motivated and well informed prior to donation.

Treatment of idiopathic retroperitoneal fibrosis by immunosuppression.

Idiopathic retroperitoneal fibrosis is exceedingly uncommon in childhood and its etiology is uncertain. Support for an immunological basis for the disease is given by a report of a 14-year-old girl with severe retroperitoneal fibrosis causing progressive azotemia in whom azathioprine and prednisolone were used successfully. This case supports the efficacy of immunotherapy in the treatment of idiopathic retroperitoneal fibrosis.

Bilateral Nephrectomy Concomitantly with Renal Transplantation

During a 2-year interval 206 patients underwent renal transplantation at a single center, 38 of whom underwent bilateral nephrectomy and other adjuvant operations as part of the transplant procedure. The indications for this type of procedure were reviewed, with special emphasis on the control of hypertension. The morbidity and mortality (16 per cent) in this group were compared in detail to those in patients not undergoing a concomitant adjuvant operation. The results with regard to renal function were similar to the group as a whole and the indications for appropriate patient selection are discussed.

1521 HYPERSPLENISM(HS) IN RENAL TRANSPLANT RECIPIENTS(TR): THERAPY WITH PARTIAL SPLENIC EMBOLIZATION(PSE)

HS complicates management of TR and limits immunosuppression, jeopardizing graft function. Splenectomy affords variable benefit but imposes risks of major surgery and potential infectious complications in immunosuppressed subjects. 3 TR and 1 patient awaiting transplantation developed severe leukopenia and/or thrombocytopenia and splenomegaly, not corrected by discontinuing possible offending drugs. 65-95% splenic infarction with Gelfoam particles were performed.In the TR improved hematologic parameters allowed increased immunosuppression and stable, or improved, graft function. Complications (fever, pain, ileus, hematoma) were not serious.PSE offers significant advantages to these patients, avoids major surgery, and has proven effective in treatment of HS.

1520 PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY IN TRANSPLANT RENAL ARTERY STENOSIS (RAS)

Hypertension(HT) due to RAS complicates 5-10% of renal transplants and jeopardizes graft function. Alternatives to surgery in immune suppressed transplant recipients are desirable. 4 subjects developed HT with hyperreninemia within 1 yr post transplant. Significant RAS was demonstrated angiographically in each. Therapy with percutaneous transluminal angioplasty produced:3 subjects remain normotensive, on no RX, 3 to 11 mos post-dilatation. Repeat arteriography at 11 mos shows no recurrence of RAS in case 1. No serious complications occurred.We concluded that percutaneous transluminal angioplasty offers an acceptable alternative to surgery in renal transplant recipients with hypertension due to renal artery stenosis.