Stanley A. Bartus

Noncompliance in organ transplant recipients.

The frequency of noncompliance with postoperative medical therapy ranges from 2% to 43% in organ transplant recipients and causes more graft loss than uncontrolled rejection in compliant patients. Retrospective and prospective studies undertaken at our center showed no difference in the rate of noncompliance between males and females or between recipients of cadaveric kidneys and those from living, related donors. Patients less than 20 years of age were statistically the most noncompliant (p = 0.0001) compared with those over 40 years. A significant difference in compliance was seen among blacks, Hispanics, and non-Hispanic whites, with the greatest frequency in blacks. This was not due to race, but to socioeconomic status, with those in the low socioeconomic group the most noncompliant. Problems of noncompliance may be reduced if they are identified early in the treatment course.

PREGNANCY IN RENAL TRANSPLANT PATIENTS A REVIEW

SUMMARY A questionnaire survey and review of the literature show that pregnancy can be well tolerated in most women with renal transplants. Fifty-two per cent of the renal transplant recipients who became pregnant had full-term infants with no serious complications. With therapeutic abortions excluded, 71% of the 308 pregnancies permitted to continue resulted in full-term infants. Rejection episodes were occasionally a serious problem, occurring in 9% of the pregnancies. Mechanical interference with renal excretion or preventing vaginal delivery occurred in 5.6% of the cases. Hypertension and proteinuria, often existing prior to pregnancy, became frequently increased during pregnancy. Infections not associated with rejection were common but easily controlled in most cases. Prematurity was frequent but related to renal function and the time interval from transplant to conception. The most serious infant complications were related to prematurity. Unknown is the future of these infants and their progeny because of their intrauterine exposure to immunosuppressive drugs.

Liver transplant for metastatic neuroendocrine tumor.

Generally, the results of liver transplantation for metastic liver disease have not been favorable. One exception has been the unique group of neuroendocrine tumors, the slow growth of which allows liver transplantation to effectively palliate and control symptoms. We report two cases: (a) A 51-year-old man who underwent orthotopic liver transplantation and resection of the pancreatic primary tumor for a nonfunctioning malignant neuroendocrine tumor with features of both carcinoid and islet-cell glucagonoma remains symptom-free and without evidence of tumor recurrence at 13 months follow-up. (b) A 47-year-old man who underwent orthotopic liver transplantation and Whipple resection fo a metastatic isletcell tumor in the head of the pancreas is fully recovered at 5 months follow-up.

Noncompliance in Organ Transplant Recipients

The frequency of noncompliance with postoperative medical therapy ranges from 2% to 43% in organ transplant recipients and causes more graft loss than uncontrolled rejection in compliant patients. Retrospective and prospective studies undertaken at our center showed no difference in the rate of noncompliance between males and females or between recipients of cadaveric kidneys and those from living, related donors. Patients less than 20 years of age were statistically the most noncompliant (p=0.0001) compared with those over 40 years. A significant difference in compliance was seen among blacks, Hispanics, and non‐Hispanic whites, with the greatest frequency in blacks. This was not due to race, but to socioeconomic status, with those in the low socioeconomic group the most noncompliant. Problems of noncompliance may be reduced if they are identified early in the treatment course.

Fibrosis of a renal transplant ureter.

Ureteral obstruction following renal transplantation, although not a common occurrence, is a serious complication because of the single functioning kidney. Obstruction may be caused by ureterovesical stenosis, retroperitoneal fibrosis or adhesions, clot formation, pelvic lymphoceles or kinking of the ureter. A case is presented in which there was progressive partial ureteral obstruction caused by fibrosis and stricture of the transplant ureter, which were probably owing to rejection episodes.

Management of antacid impactions in hemodialysis and renal transplant patients

Ten cases of intestinal obstruction caused by antacid impactions in renal transplant and hemodialysis patients were added to 16 reports in the literature. In six instances, operative intervention was necessary because of failure of vigorous medical therapy. Three patients who died had perforation of the colon at sites of stercoral ulceration due to firm antacid impactions. Aggressive medical and surgical management of constipation and fecal impaction is recommended. The outlook is grim once colonic perforation has occurred.

Pyelolithotomy of a renal transplant.

A large calculus developed in a renal transplant patient and was removed by pyelolithotomy. Hyperparathyroidism was not present. Important factors to consider before performing a nephrolithotomy in a transplanted kidney are whether the transplant was a right or left kidney and the timing of the operation in relation to renal function and infection. The etiology for renal stone formation in renal transplant recipients includes hyercalciuria, renal tubular acidosis, antacid administration and infection.

In situ cadaver kidney perfusion: experimental and clinical studies.

Lactated Ringers and Collins C2 solutions were compared in different volumes for rapid intra-aortic in situ cooling of pig cadaver kidneys. Both solutions in large volumes caused renal damage when compared with ex vivo flushed controls, although C2 was less injurious. When used for in situ cooling of human cadaver kidneys in volumes less than 1,500 ml/kidney, the two solutions were comparable and did not cause injury when compared with controls. In situ cooling permitted longer excision time (cold ischemia) and is recommended for lessening warm ischemia time in selected cases.

Renal allograft failure and cold red blood cell autoagglutinins.

Ten patients in a retrospective review of 250 kidney transplant recipients had RBC-cold agglutinins reactive at 22 C. Fourteen transplants were performed in those 10 patients. Five of nine cold renal allografts failed to function. Two of these recipients later had successful transplants when the kidneys were warmed before reestablishment of blood flow. Three other patients with cold RBC autoagglutinins had immediate renal function when the transplanted kidneys were warmed. In a prospective study of 126 patients, 59% had cold RBC agglutinins at 4 C and 11% were also reactive at 22 C. Red blood cell-cold autoagglutinins appear to be a preventable cause of acute renal allograft failure. The titer and thermal amplitude of these antibodies are probably of major importance and should always be determined before organ transplantation.

Decreased function of a renal transplant after influenza virus infection

A sixteen year old female recipient of a renal transplant had decreased renal function one month after an influenza virus infection. An acute rejection episode induced by the viral infection was the probable cause. Renal function in transplant recipients should be carefully monitored for at least one month after viral infection.