Robert E. Richie

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.

Reticulum cell sarcoma of the breast

A case of reticulum cell sarcoma of the breast with early dissemination and death despite combined therapy is reported. A literature review of 60 cases previously documented is presented. The age of occurrence is most frequent in the sixth decade. Rapid growth is the only characteristic physical finding of the lesion. The histologic pattern is predominated by a polymorphic reticular architecture. Long survival is reported following complete excision.

Renal artery dissection.

Renal artery dissections are stenotic or occlusive lesions most often observed in hypertensive patients with underlying atherosclerosis or fibromuscular disease. Acute dissections may present spontaneously, as a complication of diagnostic or therapeutic angiography or as an agonal event associated with overwhelming systemic illness. Chronic dissections may produce renovascular hypertension or be entirely asymptomatic. Fourteen renal artery dissections have been encountered in nine patients treated at Vanderbilt University Medical Center during the past decade. Eleven dissections have been found in seven patients with renovascular hypertension. Seven of these dissections were chronic (six functional, one silent) and four acute (two spontaneous, two secondary to angiography). Three agonal dissections were found in two additional patients postmortem: one at autopsy and bilateral dissections found at the time of cadaveric donor nephrectomy. Ten bypass procedures, including five complex branch reconstructions of which three were performed ex vivo, have been performed with 100% immediate patency and maintenance or improvement of renal function. Long-term follow-up of these patients has shown sustained patency of the reconstructed renal arteries, excellent blood pressure control, and normal renal function in all. Nephrectomy has not been required and there have been no associated deaths. Seventy-seven additional renal artery dissections in 72 patients collected from previous reports have been analyzed. Patient survival (55/72, 76.4%) and preservation of the involved kidney in surviving patients (26/55, 47.3%) were low in these earlier series. In addition, renal failure was associated with 59% of the deaths. The lethality of renal artery dissections and the ease and success of revascularization, which preserves renal function and ameliorates associated renovascular hypertension, emphasize the need for an aggressive approach to the recognition and treatment of this entity. Therapy should be directed toward arterial reconstructions and the preservation of functioning renal tissue.

Factors influencing the outcome of kidney transplants.

This study is a multifactorial analysis of 389 transplants performed from June 1977 to December 1981. Analyis of the effects of transfusions antilymphocyte serum (ALS), histocom-patibility testing, gender, and patient risk factors (presence of concomitant disease, greater than 50 years of age, etc.) was done. Two-hundred fifty-three patients received cadaver kidneys and 136 patients obtained kidneys from a relative. Two-hundred eighty-three (73%) patients received blood transfusions prior to transplantation. Our data showed that recipients receiving transfusions prior to transplantation had a significantly higher graft survival than those who were not transfused in both cadaveric and related graft recipients. Two-hundred twenty-one (56%) patients received ALS following the transplant. This group had a 15% higher graft survival than a comparable group. Analysis of histocompatibility testing data shows approximately 5% higher functional graft survival between each match grade. Surprisingly, female patients receiving kidneys from living related donors had a 16% higher graft survival than male patients. In cadaver recipients female patients had a 10% higher patient survival as compared to male patients. The risk factor status of recipients affected not only graft survival but patient survival, which probably is due to the consequences of immunotherapy. The authors conclusion is that the above mentioned factors may be additive in nature. Further, multivariable analysis is necessary in order to correctly transplant data.

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.

The role of HLA tissue matching in cadaveric kidney transplantation.

The role of HLA match in donor-recipient selection has been studied in 271 patients who received cadaver transplants during a 10-year period. This series included 36 four-antigen matches, 181 three-antigen matches and 54 two-antigen matches. Our results support the concept that bettor results can be expected when better matched kidneys are utilized for transplantation.

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.