Samuel L. Kountz

Avascular Necrosis of Bone after Renal Transplantation

Two groups of patients underwent renal transplantation and were managed similarly in all respects, except for the dosage of corticosteroids administered post-operatively. For the first group, sixty-eight in number, the dosage was approximately three times greater than that for the second group with 136 patients. Avascular necrosis of bone appeared in sixteen patients in the first group and in two in the second. A greatly increased incidece of avascular necrosis after repeated transplantations was noted.

Urinary lysosomal glycosidases after renal allotransplantation: Correlation of enzyme excretion with allograft rejection and ischemia

Abstract Urinary β-galactosidase, β-glucuronidase and N -acetyl- β -glucosaminidase were measured in patients with renal allotransplants and compared with normal controls. Increased excretion of all three enzymes was noted in the transplant patients resulting possibly from mild chronic rejection. A second part of the investigation correlated renal function with daily N -acetyl- β -glucosaminidase excretion by the patients. In acute rejection, enzyme levels rose sharply from a baseline then decreased following successful treatment. With cadaveric grafts and initially good urinary flow, N -acetyl- β -glucosaminidase levels were high and decreased as creatinine clearance improved; however, with initial oliguria, levels were low and rose as diuresis began then decreased to a baseline. This was attributed to a washing out of enzyme released during the unavoidable ischemic period involved in handling cadaver kidneys. Because it reflects physiological changes in the kidney, daily monitoring of urinary N -acetyl- β -glucosaminidase should be helpful in the diagnosis of renal damage caused by rejection and ischemia.

Preservation and transplantation of human cadaver kidneys.

In the last 4 years, 210 human cadaver kidneys have been stored by pulsatile perfusion for periods ranging from 4 1/2 to 50 hr. Of these 210 kidneys, 180 were subsequently transplanted. The following results are reported: incidence of postoperative dialysis for tubular necrosis, final renal function, complications, and patient and graft survival. Perfusion characteristics combined with warm ischemia time and donor serum creatinine at time of death have proved to be excellent criteria for graft viability. The clinical results show that this method of storage is efficient, reliable, and produces kidneys of excellent quality.

Prevention of wound infections by topical antibiotics in high risk patients

A study was made of the efficacy of local antibiotics in the prevention of postoperative wound infections in 354 recipients of renal transplants. There was a statistically significant difference in the rates of wound infection between patients treated with and patients treated without antibiotics, in both primary and secondary wounds. No deleterious local or systemic side effects occurred. From this study we conclude that local antibiotics, such as bacitracin and neomycin, should be used for all wounds in transplant recipients, and their use in other types of surgery is recommended.

Renal homotransplantation in children

Abstract From 1964 through 1971, sixty-three transplantations were performed in fifty-four children under the age of eighteen at the University of California Medical Center, San Francisco. Thirty-two of the children received their first renal graft from a related donor and twenty-one from a cadaver donor. In the living related donor group, survival of first grafts was 90 per cent at one year, and in the cadaver donor group it was 67 per cent at one year. Ten patients died during the eight year period. Linear growth of children who had reached their adult height prior to transplantation was favorably influenced by changing the prednisone schedule from daily doses to doses every other day. By performing retransplantation if graft failure occurred, 80 per cent of the fifty-four patients now have functioning grafts up to eight years postoperatively. These results show that children with end stage renal disease are favorable candidates for renal transplantation.

Advantages of

: Renal scintiphotography with (131)I-hippurate was the primary diagnostic procedure in evaluating renal failure and complications in over 500 transplant patients. This diagnostic test has become our principal method of evaluation and followup of renal transplants, especially in the early post-transplant period. It has accurately distinguished tubular necrosis, rejection, and other complications in the post-transplant period. Its simplicity, safety and accuracy are of great value to transplant surgeons and their patients.

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A large, comprehensive renal transplant program has a major impact not only on patient care, but also on the medical center itself and the larger community. The program at this center has advanced from 15 transplants in 1964 to 141 transplants hi 1976. Fifty-nine per cent of patients transplanted have functioning kidneys at this time, including 76 children. Rehabilitation was equal to prerenal disease level in 91% of 169 recipients who lived five years with a functioning graft. Basic research in such diverse areas as renal preservation and immunology, as well as clinical research in optimum immunosuppressive therapy, resulted in significant contributions. Refinement of the mixed lymphocyte culture improved livingrelated graft survival at two years: 100% for HLA-identical and 91% for non-HLA-identical grafts, compared to 66% reported by the Transplant Registry for the combined group. Modification of immunosuppression improved patient survival at two years: 100% and 86% for recipients of living-related and cadaver grafts, respectively, compared to 83% and 65% reported by the Transplant Registry. The complexity of care of the patient with end-stage renal failure has required active interaction between transplant surgeons and almost every major specialty. The vast clinical material has been a great asset for training transplant surgeons, nephrologists, fellows and residents of multiple specialties, and medical students. The medical centers relationship with communities within a 250 mile radius has been strengthened, as reflected in patient referrals and the development of a multi-community-supported organ procurement system, which has allowed us to perform over 100 cadaver transplants per year for the past three years. Thus the performance of 1,000 renal transplants at this center has resulted not only in rehabilitation of many renal failure patients, but also in expanded and improved research and teaching capabilities, bringing support from multiple medical disciplines and the general community.

I-orthoiodohippurate scintiphotography in the management of patients after renal transplantation

Serial measurements of glomerular filtration rate (GFR), independent and simultaneous clearances and extractions of para-aminohippurate (PAH), radiohippuran, and iodopyracet (Diodrast) were made in 11 adults and one child who received renal transplants from living donors. Measurements were made within 3 hours and repeated two to four times during the following 14 days. Immediately after transplantation, PAH clearance averaged 385 ml/min (range, 218 to 510), GFR averaged 54 ml/min (range, 22 to 87), renal plasma flow (RPF) averaged 672 ml/min (range, 309 to 1424), and marked vasodilatation was present with an average renal blood flow (RBF) of 979 ml/min (range, 435 to 2,114). As observed in other studies, immediate diuresis and natriuresis but no glycosuria occurred. Extraction ratios for PAH (EPAH) were below normal, ranging from 0.59 to 0.94, and those for 125 (or 131)I-hippuran, and 131I-Diodrast were even lower. Extraction ratio for PAH to radiohippuran averaged 1.43 in 17 simultaneous studies. However, RPF measured simultaneously with these agents was the same, indicating a true difference in transport of these substances. The low extraction ratio for PAH, 131 (or 125)I-hippuran and 131I-Diodrast was not related to depression of the maximal tubular transport of PAH and may have been a consequence of vasodilatation and increased RBF. Another observation made on these kidneys was a low filtration fraction which averaged 0.089. These hemodynamic changes did not appear to relate to circulating factors in the anephric recipient since they persisted throughout the 13-day study period in eight patients. In four patients showing transient rejection, GFR and the clearance of PAH and 131I-hippuran decreased proportionately more than RBF. It is concluded that marked vasodilatation and a low filtration fraction are characteristic of uncomplicated renal allotransplantation in man, and that early rejection is expressed by measurable decreases in the clearances of PAH and inulin despite maintenance of RBF. These changes were present prior to clinical evidence of rejection.

The impact of 1,000 renal transplants at one center.

SUMMARY A new model was devised in which rat skin with an intact vascular pedicle was used. The model was constructed by microsurgical technique. Ten skin grafts with vascular pedicle were performed from A d to Lewis rats and another 10 grafts were performed from Fischer to Lewis rats. The survival time of skin grafts with vascular pedicles, which immediately receive a blood supply after vascular anastomosis, was the same as that of full-thickness skin grafts of same strain combinations. This model demonstrated that organ ischemia and vascular pathways do not have an important role in the primary sensitization of the host by skin grafts.

Serial Hemodynamics after Renal Allotransplantation in Man

Additional operations were necessary in 67 (41%) of 162 renal allograft patients. General anesthesia was employed in all but 5 patients with no morbidity or mortality. All patients were immunosuppressed and no additional steroids were used before, during, or after the procedure. The source of the donor kidney made no difference in predicting if a recipient would require post-transplantation surgery or if an emergency or elective operation was required. Operations were necessary to correct complications either directly related to the transplant procedure (71%), or medical problems of immunosuppression or uremia (21%). Nine patients (6%) required operations unrelated to transplantation. The data indicate that transplant patients frequently need additional procedures which are directly related to the transplant operation, immunosuppression, or metabolic alterations of their past uremic condition. Mortality is related to the degree of toxicity from the immunosuppressive therapy.