Robert Soberman

Percutaneous transluminal dilation in renal transplant arterial stenosis.

Twelve hypertensive patients underwent percutaneous transluminal dilation (PTD) for relief of arterial stenosis complicating renal allotransplantation. Two patients underwent repeat PTD for recurrent stenosis and hypertension. Six patients had end to end anastomosis of the donor renal artery to the recipient hypogastric artery; four of six PTDs were successful. Six patients had end to side anastomosis of the donor renal artery to the recipient external iliac artery; seven of eight PTDs, including one of two repeat PTDs, were successful. Prior to PTD, all patients were using several antihypertensive medications. Following successful PTD, the mean blood pressure dropped from 184 ± 15/118 ± 9 to 133 ± 13/89 ± 11 mm Hg (P < 0.001) and remained at that level for up to 15 months (average followup 9 months) with decreased or no antihypertensive medications. Since surgical correction of arterial stenosis occurring after renal transplantation is difficult and may endanger the graft, PTD should be the first interventional therapy.

Long-term effects of pancreatic transplant function in patients with advanced juvenile-onset diabetes.

Present methods of management of juvenile-onset diabetes mellitus do not prevent serious and debilitating complications affecting multiple organ systems. In an effort to reverse advanced forms of these complications, segmental transplantation of the pancreas has been performed on 10 patients, seven of whom simultaneously or subsequently received renal transplants. Long periods of normoglycemia (two to four and one-half years) were achieved in two patients who also maintained transplant kidney function. The course of these two patients is described to illustrate the possible value and limitations of the procedure. These patients had normal blood glucose levels, exhibited repeated normal intravenous glucose tolerance curves, and had repeated normal endogenous insulin levels. Their courses were characterized by (1) absence of problems related to pancreatic exocrine secretions into the bladder; (2) stable eye changes despite some episodes of hemorrhage from preëxisting retinopathy; (3) vascular complications, including stroke and gangrene of extremities necessitating amputation despite successful femoropopliteal bypass grafting; (4) peripheral neuropathy; and (5) repeated infections. Both patients succumbed to vascular complications. Thus, pancreatic transplantation can maintain blood glucose and insulin at normal levels for extended periods of time. However, it does not reverse such complications as advanced retinopathy or atherosclerosis. Since the procedure may have value in preventing progression of these complications, it should be evaluated in patients with less advanced complications of diabetes.

Male fertility in cyclosporine-treated renal transplant patients

Fertility and potential fertility were evaluated in 9 young men on cyclosporine A therapy following renal transplantation. Semen analysis was normal in most parameters in 8 patients as was testicular hormonal function. Of 4 men who had attempted to impregnate their wives 3 succeeded. Cyclosporine A does not seem to affect adversely fertility in men.

Pancreatic duct to ureter anastomosis for exocrine drainage in pancreatic transplantation

Abstract 1. 1. Four cases of segmental pancreatic transplantation are reported. 2. 2. Experimental studies of pancreatic duct to ureter anastomosis in the dog are summarized. 3. 3. The technic of segmental pancreatic transplantation and of pancreatic duct to ureter anastomosis is described. 4. 4. The pancreatic duct to ureter anastomosis, both experimentally and clinically, is a simple, effective technic for providing exocrine drainage of the transplanted pancreatic segment. 5. 5. The three patients receiving segmental pancreatic transplants are alive. Two have functioning pancreatic grafts, one beyond six months. This last patient also has a functioning kidney transplant.

ALG treatment of steroid-resistant rejection in patients receiving cyclosporine.

Thirty-one episodes of biopsy-proved acute rejection (R) in 28 patients maintained on cyclosporine did not respond to high-dose steroids and were treated with antilymphocyte globulin (ALG). Cyclosporine was discontinued in all but three during ALG administration. (A) Twenty-four patients received 26 courses of ALG within 90 days of transplant (11 1st R, 15 2nd or 3rd). Seven treatment courses were cut short due to infection (4), ongoing R (2) and a combination of infection and rejection (1). Only 1 of 7 has a functioning graft. Of the remaining 19 full ALG courses (17 patients) (8 1st R, 11 2nd or 3rd), 13 (11 patients) responded (7 1st R, 6 greater than 1st). The remaining 6 patients lost their grafts to ongoing acute rejection. (B) Five patients were treated after 6 months posttransplant; two responded but no grafts currently function

Successful kidney transplantation with current-sera-negative/historical-sera-positive T cell crossmatch

Etude de 5 observations: 1 rejet accelere, 1 rejet au bout de 3 mois, 3 bons resultats, reins transplantes fonctionnant depuis 10, 14 et 17 mois

Recurrent Membranoproliferative Glomerulonephritis Type 1 in Successive Renal Transplants

We report a man who developed renal failure due to membranoproliferative glomerulonephritis (MPGN) type 1 which recurred in two cadaveric kidney transplants. This is the third such case in the literature. Nephrotic syndrome developed within 1 month following transplantation and histologic evidence of disease recurrence was documented in both kidneys 2 months after transplantation. Both grafts failed within 18 months. Factors which determine disease recurrence remain obscure.

Individualization of immediate posttransplant immunosuppression: the value of antilymphocyte globulin in patients with delayed graft function

In patients with delayed graft function (DGF), the use of cyclosporine (CsA) has been reported to prolong DGF, increase the number of required dialyses, increase the duration of hospitalization, and be associated with decreased graft survival. Routine postoperative antilymphocyte globulin (ALG) use has been advocated, but ALG is associated with increased viral infection. We studied outcome of individualization of immunosuppression. Between 11/84 and 8/86, first-cadaver transplant recipients whose serum creatinine (Cr) fell >30% in the first 24 hr (immediate function) were started on CsA and prednisone (P) (group 1, n=26). The remainder were randomized to P and azathioprine (group 2, n=32) or P and ALG (group 3, n=26), and switched to CsA when serum Cr fell >30% (minimum 5 days ALG for the ALG group). P taper was the same in all groups. Patients with DGF (groups 2 and 3) had longer preservation time and higher peak PRA (P<.05) than group 1. Groups were otherwise equivalent. One and 2-year patient survival was 96% (3 cardiovascular deaths; all with functioning grafts). One-year graft survival was 87% for group 1, 87% for group 2, and 82% for group 3(NS). In patients requiring dialysis, mean day off dialysis was 12±3 in both groups 2 and 3. Mean hospital stay was 12.5±1.3 days for group 1, 21.6±2.1 days for group 2 (P<.05 vs. 1 & 3), and 14.5 ± 1.2 days for group 3 (NS vs. 1). The increased hospital stay for group 2 patients was mainly due to increased in-hospital rejections: 75% for group 2, (P<.05 vs. group 1 [35%], and group 3 [11.5%]). In addition, more group 2 in-hospital 1st rejections were steroid resistant as compared to group 1; 46% group 1 patients have remained rejection free as compared to 0% group 2 (P<.05 vs. 1 and 3) and 35% of group 3 (P<.05 vs. 1 and 2). Mean serum creatinine at 6–12 months remained higher in patients with DGF (group 1 P<.05 vs. 2 and 3). Rejection was the major cause of graft loss in all groups. There was no difference between groups in the incidence of infection. We conclude that: (1) with individualization of immunosuppression, graft survival is equivalent with and without DGF; (2) Cr remains higher in patients with DGF; (3) in patients with DGF, ALG or azathioprine in the immediate postoperative period gives equivalent graft survival; prophylactic ALG is associated with significantly decreased early rejection and hospital stay, and with more patients remaining rejection free.

Timing of cyclosporine administration in patients with delayed graft function

Cyclosporine in renal transplant recipients with delayed graft function (DGF) has been reported to decrease graft survival and prolong both DGF and hospitalization. In some centers, antilymphocyte globulin (ALG) has been used perioperatively to obviate these problems, but ALG is associated with increased viral infections. In this study, first cadaver transplant recipients with a fall in serum creatinine level of greater than or equal to 30% in the first 24 hr were started on prednisone (P) and cyclosporine (Group 1, n = 18). Those whose creatinine level did not fall were started on P and azathioprine (Group 2, n = 23) and switched to P and cyclosporine when serum creatinine fell 30%. One-year patient survival was 98%. One-year graft survival was 83% for both Groups 1 and 2 (NS). Results were compared to historical controls with DGF who received P and cyclosporine (Group 3, n = 19). Patients with DGF and requiring dialysis had fewer dialyses (P less than 0.05) and a shorter hospital stay (P less than 0.05) if started on azathioprine, as compared to those started on cyclosporine. Patients with DGF had a higher serum creatinine at 12 months than those with immediate function (P less than 0.05). We conclude that withholding cyclosporine until DGF is resolving decreases the duration of dialysis, decreases hospital stay, and without the use of prophylactic ALG, is associated with graft survival equivalent to that in patients with immediate function.

Treatment of renal transplant rejection episodes in patients receiving prednisone and azathioprine. A cost-effective approach.

Antilymphocyte globulin (ALG) has been advocated for the treatment of renal transplant rejection episodes in patients maintained on prednisone and azathioprine. Treatment with steroids (outpatient) is considerably less expensive than with ALG (inpatient), so we studied whether routine ALG was necessary. Between 3/82 and 11/83, 54 cadaver transplant recipients maintained on prednisone and azathioprine who developed a first rejection episode were randomized to receive–for treatment of their first, and if necessary second, rejection– methylprednisolone (MP) plus ALG (n = 24), or MP alone, with ALG added if treatment failed (n = 30). Treatment failure was defined as continuing deterioration on T131 iodohippuran scan, rising serum creatinine level, or lack of improvement within 7 days. There was no significant difference in patient survival, graft survival, mean number of rejections, and infection rate between the two groups: 60% (18/30) of first and 50% (10/10) of second rejection episodes responded to MP alone. We conclude that patients are not penalized by initial rejection treatment with MP. Many rejection episodes respond to steroids alone; elimination of routine ALG use will save hospitalization time and expense.