Stephen B. Leapman

Renal transplantation into the reconstructed bladder.

In our experience with 821 renal transplants performed between 1974 and October 1987 we used the native or reconstructed bladder of the patient in all but 2 instances. Seven patients have undergone enterocystoplasty and subsequent renal transplantation, while 1 underwent bladder augmentation after transplantation. Of these 8 patients 4 have functioning grafts 6 months to 7 years after transplant or reconstruction. Renal transplantation coupled with enterocystoplasty in properly selected patients has acceptable morbidity and should be considered as an alternative to other forms of urinary diversion in allograft recipients.

Abdominal wall and inguinal hernias in continuous ambulatory peritoneal dialysis patients

This retrospective analysis of 140 continuous ambulatory peritoneal dialysis patients followed during a 4 year period revealed a 5 percent incidence of abdominal wall hernias. Inguinal hernias were frequently manifested as unilateral scrotal swelling. Hernias too small to be appreciated by physical examination were easily demonstrable with intraperitoneal instillation of technetium 99m sulfur colloid through the continuous ambulatory peritoneal dialysis catheter. This procedure was also useful when differentiating dialysate leaks from inguinal hernia in the early and late postoperative periods. Recurrences developed in 27 percent of the herniorrhaphies. Factors contributing to the development of abdominal wall hernias in continuous ambulatory peritoneal dialysis patients include uremia, obesity, anemia, and chronically elevated intraperitoneal pressures.

Therapy of acute cadaveric renal allograft rejection with adjunctive antithymocyte globulin.

A randomized and controlled study was conducted to evaluate the efficacy of adjunctive antithymocyte globulin (ATG) therapy for the treatment of the initial rejection episode in first cadaveric transplants. When compared to the control group (29), which received only standard antirejection treatment (SAT) of steroid pulsing and local irradiation, the adjunctive ATG treatment group (23) demonstrated significantly faster recovery rates (8.9 ± 4.1 versus 6.9 ± 3.7 days, P = 0.05, respectively) and better graft survival rates (62 ± 9% versus 91 ± 7%, respectively) after the first rejection. ATG treatment did not result in fewer subsequent rejection episodes than SAT but long-term allograft survival rates remained superior to controls for the entire 3-year study period. By avoiding ATG treatment in those patients who never experienced clinical rejection on maintenance immunosuppressive therapy, i.e., nonresponders (23 of 90), complications associated with excessive immunosuppression were minimized. The combined results of the non-responder group of patients and ATG-treated patients resulted in a 1-year patient survival of 97% and graft survival of 86%. These results suggest that the most efficacious use of ATG is therapeutic and not prophylactic in renal transplant patients.

Impaired immune function in obstructive jaundice

Sepsis is a common and occasionally lethal complication of obstructive jaundice. The reasons for this increased susceptibility to infection are unknown. This study examines lymphocyte and reticuloendothelial (RES) function in animals with obstructive jaundice. Twelve New Zealand white rabbits (3-4 kg) were studied. Lymphocyte function was evaluated in six rabbits by phytohemagglutinin (PHA), concanavalin A (Con A), and pokeweed mitogen (PWM) stimulation. In six animals, hepatic RES function was assessed by calculating the phagocytic index (PI) using the disappearance of 99Tc sulfacolloid (5 mg/kg) iv. After baseline studies, the common bile duct was divided and ligated. The above studies and serum bilirubin were repeated at 3 weeks. Obstruction was then relieved by cholecystojejunostomy (CJ) and RES studies repeated monthly x 6. Preobstructive lymphocyte function showed a stimulation index ratio (log) of 0.85 +/- 0.25 for PHA, 0.75 +/- 0.3 for Con A, and 0.71 +/- 0.25 for PWM. With biliary obstruction, the values fell to -0.23 +/- 15 (P less than 0.006), -0.31 +/- 0.12 (P less than 0.006), and -0.29 (P less than 0.006), demonstrating impaired lymphocyte function. When tested lymphocytes were mixed with control pooled rabbit serum, however, no lymphocyte impairment was noted. Baseline hepatic PI was 6.02 +/- 0.18 and fell to 3.79 +/- 0.33 with obstruction (P less than .01) and remained low at (3.20 +/- 0.14) 1 month (P less than 0.01) and (3.33 +/- 0.23) at 3 months (P less than .01), after CJ but returned to normal (8.04 +/- 0.97) at 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

The Manifestation and Management of Late Urological Complications in Renal Transplant Recipients: Use of the Urological Armamentarium

The incidence of urological complications in renal transplant patients is well documented. The majority of these complications occur in the early postoperative period; late occurrences (more than 3 months) are much less common. We have had experience with 7 patients who presented with late complications 3 months to 7 years after transplantation: ureteral obstruction occurred in 4 patients, ureteral disruption or laceration in 2 and neurogenic bladder with hydronephrosis in 1. Management of these patients has been varied and has included cystoscopic stent placement, Boari flap, ureteropyelostomy, ureteroneocystostomy, bladder augmentation and urinary undiversion. Grafts have been salvaged in 6 of 7 patients. Transplant patients who present with late urological complications can be challenging. However, the potential for intervention and graft salvage is excellent.

Clinical Application of the Kidney to Aortic Blood Flow Index (K/A Ratio)1

The kidney to aortic blood flow index (K/A ratio) is the ratio of the slopes of the upstrokes of renal and aortic histograms, derived from regions of interest applied to sequential gamma camera images of the first transit of a 99mTc bolus. This index proved in our previous dog studies to have a good correlation with renal artery blood flow. In the 190 clinical studies of renal allografts reported here, the K/A ratios correlate well with independently established retrospective clinical-pathologic assessment of renal functional status. Normal range for the K/A ratio was established in 50 patients with no demonstrable renal disease. Tests of inter-observer reproducibility show a mean relative standard deviation of 7% for independently performed analyses on the same data.

In Vitro Effects Of Cyclosporin A On Lymphocyte Subpopulations: 1. Suppressor Cell Sparing By Cyclosporin A

The fungal metabolite, cyclosporin A, is a potent immunosuppressive compound. Experiments were performed in vitro with both human and nonhuman primate peripheral blood lymphocytes to study the effect of this agent on suppressor cell activity. Cyclosporin A did not affect the generation or function of concanavalin A-induced suppressor lymphocytes as measured by their ability to suppress thymidine uptake of lymphocytes in secondary cultures. No evidence of suppressor cell induction was noted by incubation of lymphocytes with only cyclosporin A. We conclude that, although cyclosporin A does not generate or induce suppressor cell lymphocytes, it does spare them, while inhibiting other subpopulations. This effect may create an imbalance in the immune system which results in profound suppression.

Pseudorejection: the Page kidney phenomenon in renal allografts.

A case of renal allograft pseudorejection owing to perinephric hematoma is presented and the Page kidney phenomenon is discussed as the pathophysiologic mechanism. The term pseudorejection is introduced and defined as a remediable form of graft dysfunction resulting from renal parenchymal compression. Sonography was helpful, in addition to the standard diagnostic modalities in making the diagnosis. Early recognition and decompression of a peritransplant hematoma or lymphocele may decrease graft loss from this insidious entity.

Elective and emergency surgery in renal transplant patients.

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.

Intraoperative placement of a Wallstent for portal vein stenosis and thrombosis after liver transplantation.

We report a case of orthotopic liver transplantation, in which portal vein thrombosis developed in the immediate postoperative period. Surgical thrombectomy and intraoperative placement of a large caliber Wallstent resulted in long-term patency. The unique feature of this case is the intraoperative placement of the stent via the inferior mesenteric vein under fluoroscopic guidance. The use of a large caliber (16 mm) stent obviated the need for postoperative anticoagulation.