Hyperglycemic pseudorejection in the diabetic transplant patient

Serum creatinine elevation in a stable transplant recipient most often suggests rejection of the transplant and requires further evaluation and management. In our series of juvenile diabetic patients who have received kidney transplants, we frequently have observed creatinine elevations in association with hyperglycemia. Correction of the hyperglycemia resulted in return of serum creatinine to normal levels and no rejection therapy was required. To better define this syndrome, 2,734 paired measurements of blood glucose and serum creatinine were obtained in 52 stable post-transplant diabetic patients. A mean increase in blood glucose of 100 mg. per 100 ml. was found to increase serum creatinine by 0.5 mg. per 100 ml. in these patients (r=0.93; p less than or equal to 0.001). Evidence strongly suggests that the pathogenesis of this phenomenon is not a result of a laboratory artifact due to the technique used to determine serum creatinine. The pathogenesis may be due to the increased serum osmolarity and resulting intracellular dehydration associated with hyperglycemia. Recognition of this syndrome is important to all centers participating in the care and management of the diabetic transplant recipient.

Uremic pericardial effusion. Treatment by catheter drainage and local nonabsorbable steroid administration

Pericardial drainage via percutaneous catheter placement and local nonabsorbable steroid instillation was employed as definitive therapy for uremic patients who had intractable pericardial effusions. Twelve patients are reported. Prior daily dialysis, and in one case systemic steroids, were not curative. 11 of 12 cases suffered severe tamponade requiring pericardiocentesis. One patient had an organized pericardial effusion, making pericardiocentesis impossible. He required pericardiectomy with prolonged hospitalization (2 weeks) due to postoperative complications. There were no complications in the 11 patients where catheter drainage and local steroid instillation were employed. No patient had recurrence of his pericardial effusion (followed from 2 weeks to 32 months). Instillation of a relatively nonabsorbable steroid through an indwelling pericardial catheter provides immediate and lasting relief without either the inconvenience or postoperative complications and prolonged hospitalization associated with the surgical procedure of pericardial fenestration. This report offers initial evidence that the percutaneous approach may be a safe and effective alternative to pericardial fenestration in most uremic patients with pericardial effusion.

Successful renal transplantation in patients with prior history of malignancy

Eleven selected patients with a history of cancer have received renal transplants. In three patients the malignancies were diagnosed and treated before renal failure developed. Two patients underwent bilateral nephrectomies for the treatment of bilateral renal malignancy. In six patients the malignancy developed while they were uremic, and they received transplants after treatment of the tumor. Recurrent tumor developed in only one of the 11 (9 per cent) patients after receiving the transplant. Thus, patients with a history of malignancy can receive a transplant without accelerating growth of the tumor. We recommend a minimum period of one year between tumor treatment and transplantation to observe for tumor recurrences or metastases. A longer period of observation may be necessary in patients who have tumors with a poorer prognosis.

Chronic antigenic stimulation, herpesvirus infection, and cancer in transplant recipients

An increased incidence of malignancy has been reported in transplant recipients. The pathogenesis of this increase was originally attributed to immunosuppressive therapy. However, not all tumours are increased in proportion to their occurrence in the general population-75% of reported tumours are lymphorproliferative or carcinoma of the skin, lip, or cervix. This cannot be explained by impaired immunosurveillance, and alternative hypotheses must be considered. 90% of transplant recipients develop clinical or serological evidence of herpesvirus infection. Herpesviruses have been implicated in the pathogenesis of lymphorproliferative tumours and carcinoma of the skin and cervix. They can remain in latent form and be reactivated by allogeneic stimulation and/or immunosuppression. These viruses localise to skin, cervix, and neural tissue-i.e., exactly those sites where cancer develops in transplant patients. Herpesvirus infections in association with the presence of an allogeneic graft in an immunosuppressed patient may be responsible for the increased incidence of both lymphoproliferative tumours and carcinoma of the skin, lip, and cervix in the transplant recipient.

Lethal complications of bilateral nephrectomy and splenectomy in hemodialyzed patients

Routine bilateral nephrectomy and splenectomy (BNS) in uremic patients before transplantation are relatively safe procedures except when there is pre-existing sepsis, diabetes, or severe hypertension. A review of 421 patients undergoing routine pretransplantation BNS reveals that death before transplantation occurs in two definable groups of patients. In our series, the first group, those with juvenile onset diabetes, have a 15.4 per cent pretransplantation mortality (9.6 per cent operative and 5.8 per cent nonoperative) while being maintained on hemodialysis and awaiting transplantation. The second group, nondiabetic patients with other preoperatively definable risk factors such as severe hypertension and infected kidneys, had a 3.25 per cent pretransplantation mortality (1.9 per cent operative and 1.25 per cent nonoperative) while on hemodialysis. Paradoxically, these same factors are used as absolute criteria for pretransplantation nephrectomy at institutions where this operation is not a routine part of the pretransplantation regimen.

Increased incidence of malignancy during chronic renal failure

The incidence of cancer in 646 dialysis/transplant patients before uraemia developed, during the period of progressive uraemia, and post-transplantation was compared. 10 tumours (3 breast, 2 kidney, 1 leukaemia, 1 lung, 1 insulinoma, 1 thyroid, 1 cervix in situ) developed in 9 patients during the period of progressive uraemia, a significant increase over the expected number in the age-matched general population. 6 of these patients have received transplants and have no evidence of recurrent disease 6 months to 4 years post-transplantation. 11 de-novo tumours have developed in 530 transplant recipients (4 cervix in situ, 2 skin, 2 reticulum-cell sarcoma, 1 lip, 1 dysgerminoma, 1 colon)--a significant increase over the age-matched general population. The cancers in the uraemic patients are relatively common types of mesenchymal tumours while the cancers in the transplant recipients are epithelial and lymphoproliferative. This difference may reflect the presence of the graft in the transplant patient or may be due to different patterns of immunosuppression in these two populations.