[Personal experience with simultaneous transplantation of pancreas segment and kidney]

Between February 1988 and December 1994, 25 patients underwent simultaneous kidney and segmental pancreatic transplantation. Diabetes type I with the end-stage renal disease secondary to the diabetic nephropathy was the indication for this procedure. The original method of the four vascular anastomoses was introduced to prevent early pancreatic graft thrombosis. The cross section of the pancreatic segment was anastomosed to Roux--en Y loop in 80% cases and in 20% ductal occlusion with Ethiblock was performed. One-year survival rate for kidney and the pancreas was 81% and 57% and five - years survival rate 57% and 42%, respectively. One - year and five - year survival rate for the patients was 72% and 68%, respectively. The most serious complication leading to the graft removal was intrapancreatic abscess. Sepsis was the main cause of the death among transplant patients.

[Orthotopic liver transplantation in a patient with primary biliary cirrhosis]

In December 1994 an orthotopic liver transplantation was performed in a 46-year old female patient with liver failure due to primary biliary cirrhosis. The patient was discharged on the 31-st postoperative day. The graft was obtained at the multi-organ harvesting. The results of the donor's biochemical tests and the histological estimation of the graft tissue allowed to prognose a successful postoperative course.

[Toxoplasmosis as a risk factor in pregnant women after renal transplantation]

Toxoplasmosis is an anthropo-zoonosis caused by the protozoa Toxoplasma gondii. The frequency of infection in the population of adults is estimated at 30-50%. Acquired toxoplasmosis takes a differentiated clinical course. It is usually symptomless or the symptoms are indistinct. In case of immunosuppressive treatment of the host severe Toxoplasma gondii infections can occur. There also is a possibility of transmission of the protozoa via transplant from the donor to the recipient as well as the possibility of reinfection of the acquired infection. In perinatal medicine toxoplasmosis plays a particularly important part due to the possibility of the transmission from mother to foetus. It seems therefore that women who are chronically treated with immunosuppressive eg after a renal transplant deserve special medical attention.

Correction of posttransplant erythrocytosis with enalapril

Erythrocytosis (i.e., elevation in red cell mass) frequently develops after renal transplantation and is associated with increased risk of thromboembolic incidents and hypertension. Because it has been reported that enalapril may induce anemia in renal allograft recipients, we have undertaken a prospective study to estimate the efficacy and safety of enalapril therapy for erythrocytosis and to establish the mechanism by which enalapril reduces red cell mass. Seventeen (12 male and 5 female) long-term renal allograft recipients with increased hematocrit value (> 55% for male and > 50% for female) and elevated red cell mass as determined with 51Cr-labeled autologous erythrocytes were treated with enalapril. After 3 months of therapy, enalapril was withdrawn and patients were observed in order to differentiate spontaneous remission of erythrocytosis from effects of enalapril therapy. After 3 months of the treatment, mean hematocrit decreased from 51.1% (range 47-56%) to 42.9% (range 37-51%; P < 0.01). Red cell mass significantly decreased during this period (from 46.7 ml/kg, range 32.5-60.7 ml/kg, to 32.9 ml/kg, range 20.1-60.1 ml/kg; P < 0.01). Serum erythropoietin levels also changed from 12.2 mIU/ml (range 1.0-33.0 mIU/ml) at baseline to 5.4 mIU/ml (range 0.7-24.2 mIU/ml; P < 0.05). During the following 3 months without enalapril treatment, an increase in hematocrit was noted, reaching 51.7% (range 46-58%; P < 0.05). No serious side effects of enalapril were observed during the study, but there was a need to reduce other hypotensive drugs in some patients. Serum creatinine did not change significantly during enalapril therapy (1.49 mg/dl, range 0.9-2.3 mg/dl, and 1.55 mg/dl, range 1.0-2.3 mg/dl; before and after 3 months of therapy, respectively). Our study proves that enalapril can be safely and effectively used to treat posttransplant erythrocytosis. The effect of enalapril on red cell mass results from reducing erythropoietin production.

[Testing the efficacy of fluconazole in treatment of oral and throat candidiasis in patients after kidney transplantation]

Eleven kidney transplant recipients with the oral or/and throat candidiasis which occurred during the first 3 months after transplantation were studied. Fluconazole was administered orally in the dose of 50 mg each 24, 48, 72 h, according to creatinine clearance. No clinical symptoms of candidiasis on the third day of the treatment were observed. In all patients, negative mucosal cultures were noted at the 8th day after first fluconazole dose. During fluconazole was with in normal range. Furthermore, no changes in serum bilirubin alanine transaminase, lactate dehydrogenase and alkaline phosphatase activities were observed. Serum creatinine decreased during this follow-up. In the 30th day after fluconazole administration cessation the mycological evidence of Candida p. reinfection were noted in 25% of patients. Fluconazole is highly efficient and safe agent to manage the oral and throat candidiasis in renal transplant recipients.

[Levels of beta-2-microglobulin (B2MG) in blood serum of patients during the early phase after kidney transplantation]

In uremic subjects serum B2MG levels was significantly higher than in normals. In kidney transplant patients (KTP) serum B2MG levels was 3-4 times higher than in normals. Elevated serum B2MG levels in KTP seems to depend not only on the kind of immunosuppressive therapy but also on other factors. In the present study we aimed to asses serum B2MG levels immediately after KT. B2MG were assessed in 25 uremic patients at the early phase after KT and in 12 controls (patients immediately after cholecystectomy). All uremic patients were divided on two groups: group I-patients with immediately graft function after transplantation (12 patients) and group II--patients with acute failure of the transplanted kidney (13 patients). In all examined subjects immediately before and 1, 2, 3, 4, 5, 10, 15, 20, 25, and 30 days after transplantation serum B2MG levels were assessed using RIA methods. In group I we observed gradually decline of B2MG concentrations parallel with creatinine after KT while in group II normalization of B2MG and creatinine levels were delayed (approximate 10 days). The significant positive correlation was found between plasma B2MG and creatinine levels in all examined patients. We concluded: 1. In all examined groups the tendency to normalization of B2MG levels after KT was observed. 2. Acute failure transplanted kidney delayed normalization of B2MG concentrations. 3. Normalization of B2MG levels was preferentially dependent on the graft function.

Effect of enalapril on proteinuria after kidney transplantation

We studied the effect of enalapril, an inhibitor of angiotensin-converting enzyme (iACE), on proteinuria and renal function in recipients of renal allografts. Twenty-two patients with post-transplant nephrotic syndrome were treated with incremental doses of enalapril for 1 year. Urinary protein excretion decreased after 2 months of treatment from a mean of 8.9 g/day (range 4.0-18.9 g/day) to 4.5 g/day (range 0.4-10.0 g/day; P < 0.01) and remained significantly low for the rest of the study. However, in the same period, creatinine clearance did not change significantly; it went from 47.8 ml/min (range 17.1-110.3 ml/min) before treatment to 44.2 ml/min (range 16.5-88.5 ml/min) after 2 months of iACE therapy. Analysis of individual data showed that there was a significant reduction in proteinuria in 14 of the 22 patients and that the rate of deterioration of renal function did not increase in 17 of the 22 patients. We did not observe any serious side effects of enalapril administration. The results of our study prove that iACE can be used safely and effectively to reduce post-transplant proteinuria.

[Acute failure of transplanted kidney after administration of angiotensin converting enzyme inhibitors (iACE)]

Treatment of kidney transplant recipients with inhibitors of angiotensin-converting enzyme (iACE) is associated with increased risk of deterioration of renal function. Between 1988-1992 in Transplantation Institute, 71 renal allograft recipients were treated with iACE. 44 of them received iACE in order to reduce proteinuria, 18 due to secondary polycythemia and 9 recipients received iACE because of hypertension resistant to at least 3 hypotensive drugs. Acute renal failure developed in 5 patients and all of them received iACE as treatment of resistant hypertension. After resumption of renal function, in 3 of 5 patients artery stenosis of the transplanted kidney was found. In 1 recipient acute renal failure occurred despite normal renal arteriography and normal indexes of the flow through renal arteries determined by Doppler ultrasound examination. In 2 patients acute renal failure appeared after a single minimal dose of iACE. Severe arterial hypertension in patients with transplanted kidney is a particular risk factor for development of acute renal failure after iACE. The normal arteriography in transplanted kidney and normal arterial blood flow measured by means of Doppler ultrasound do not exclude the possibility of development of acute renal failure after iACE.

[Effect of immunosuppression method on levels of plasma erythropoietin (EPO) and parathyroid hormone (PTH) during acute graft rejection in kidney transplantation (KTP)]

Acute rejection is characterized by renal ischaemia which in turn is a triggering factor of EPO synthesis. On the other side during acute rejection (AR) the plasma PTH level (which is incriminated as an uraemic toxin) increases. This facts justified our present study which aimed to assess: 1. the influence of acute graft rejection (AR) on plasma EPO and PTH levels in KTP and 2. the influence of kind of antirejection therapy i.e. high dose of methylprednisolone (MP) vs thymoglobuline (TG) + moderate dose of methylprednisolone on plasma EPO and PTH levels respectively. A total of 28 KTP were studied who were divided into two groups: the first one designed as group MP comprised 17 KTP treated by high doses of MP while the second one designed as group ATG--consisted of 11 KTP treated by thymoglobulin+moderate doses of MP. The control group consisted of 16 healthy subjects. Before AR KTP showed inappropriately reduced EPO plasma levels when related to the degree of anaemia. AR was accompanied by a significant increase of plasma EPO and PTH levels in all examined KTP groups. After subsidence of AR normalization of plasma EPO and a significant decline of plasma PTH was noticed. A significant positive correlation was found between plasma EPO and PTH levels before the AR period in both examined groups.

CONCLUSIONS

1. KTP are characterized by relative EPO deficiency at the immediate (2-3 weeks) post transplantation period. 2. AR episodes are characterized by a significant rise of both plasma EPO and PTH levels. 3. Changes in plasma EPO and PTH do not seem to be interrelated at the AR episodes.(ABSTRACT TRUNCATED AT 250 WORDS)

[Serum erythropoietin level during acute rejection of transplanted kidney]

Acute rejection is characterized by renal ischaemia which in turn is a triggering factor of EPO synthesis. This fact justified our present studies which aimed to assess the influence of acute rejection (AR) on plasma EPO level in KTP. A total of 17 KTP were examined some days before AR (I), at the onset of AR (II), immediately (III) and some days after (IV) discontinued therapy of AR episodes by methylprednisolone. The control group consisted of 16 healthy subjects. KTP 2-3 weeks after renal transplantation showed relative EPO deficiency both during efficient excretory function and rejection episodes. At acute graft rejection episodes a marked increase of plasma EPO level was found. Results presented in this study suggest absence of the physiological relationship between EPO secretion and erythropoiesis 2-3 weeks after transplantation.

[Plasma erythropoietin levels in patients with stabilized function of the transplanted kidney]

Plasma erythropoietin level was assessed in 96 kidney transplant patients with stabilized function of the graft 3 months up to 5 years after transplantation and in 16 healthy subjects. In kidney transplant patients on CyA or azathioprine respectively, plasma erythropoietin levels were significantly higher during the first three months after transplantation than in normals. Normalization of erythropoietin levels were observed 6 to 12 month after kidney transplantation. As compared with patients on CyA, in azathioprine treated patients plasma erythropoietin levels were significantly higher 12 to 60 months after transplantation. These elevated erythropoietin levels in azathioprine treated patients seem to be due also to factors other than higher prednisone dosage.

[Plasma erythropoietin levels in kidney transplant patients with impaired function of the renal graft]

In 81 patients with failing kidney transplant, plasma levels of erythropoietin, iron, ferritin and TIBC were assessed. Progression of failure of the excretory function of the kidney transplant was accompanied by decreasing Hb and Ht values but increasing plasma levels of erythropoietin. In all examined patients presence of iron deficiency could be excluded. Results obtained in this study suggest that relative erythropoietin deficiency is the major cause of anaemia in patient with a failing kidney transplant.

[Level of erythropoietin and parathormone in blood plasma during acute rejection of kidney transplant]

The acute rejection of kidney transplant is accompanied by kidney ischaemia which in turn is a triggering factor for erythropoietin (EPO) synthesis. It was shown, on the other hand, that during the rejection an increase in blood serum parathormone (PTH) concentration takes place. The present study was aimed at answering the question what is the effect of acute rejection of kidney transplant on blood serum concentrations of EPO i PTH. Seventeen patients with kidney transplant participated in the study. In all the patients the investigations were carried out four times: 1--few days before rejection, 2--after ascertaining that kidney transplant is being rejected, 3--immediately after rejection, and 4--few days after completing the anti-rejection therapy. High doses of methylprednisolone were used as anti-rejection therapy. Control group consisted of 16 healthy persons. Acute rejection of kidney transplant was accompanied by a significant increase in blood serum concentrations of EPO and PTH. After methylprednisolone therapy, normalization of EPO and decrease in PTH concentration were observed in kidney transplant patients. Significant positive correlations were found between EPO and PTH concentrations in blood serum. It was concluded that acute rejection of kidney transplant is characterized by a significant increase in blood serum concentrations of EPO and PTH. Despite the existence of a significant positive correlation between blood serum concentrations of EPO and PTH in patients with kidney transplant, any pathogenic relation between the observed disturbances of secretion of the two hormones seems to be of little probability.

[Renin activity and aldosterone level in the plasma of children with lipoid nephrosis]

In 16 children with steroid-responsive nephrotic syndrome (with minimal changes in the glomeruli) the plasma renin activity and aldosterone level were determined during recurrence of the nephrotic syndrome at the stage of oedema increase (FEN alpha 0.25%) and in early period of remission. Plasma renin activity was raised in all cases suggesting presence of hypovolaemia. Since it was not possible to establish a correlation between plasma renin activity and albumin level, as well as between this activity and aldosterone level, and aldosterone level and sodium excretion it may be surmised that the renin-angiotensin-aldosterone system has no decisive role in the pathogenesis of the nephrotic syndrome. The mechanism of oedema development is doubtlessly more complex.

Endocrine abnormalities in patients with endstage renal failure

Data presented in this study suggest existence of hyperendorphinism in uraemic patients. This hyperendorphinism may be regarded both as a primary beneficial compensatory mechanism counteracting disturbances of the internal environment, while causing secondary harmful side effects, which contribute to the uraemic state. Erythropoietin treatment of uraemic, haemodialyzed patients is followed by marked endocrine alterations (suppression of plasma levels of STH, ACTH, prolactin, glucagon, aldosterone, cortisol and plasma renin activity, elevation of plasma insulin and atrial natriuretic levels, lack of influence on plasma PTH, CT and AVP). It remains to be clarified whether the erythropoietin induced endocrine alterations are due to correction of the existing anaemia or reflect a specific effect of this hormone.

Long-term immunosuppressive therapy of idiopathic membranoproliferative glomerulonephritis

Fifty cases of idiopathic membranoproliferative glomerulonephritis were followed up for an average of 10 +/- 0.9 (SE) years. Forty of them, who presented a nephrotic syndrome, were treated by immunosuppressive drugs (prednisone, azathioprine, chlorambucil, cyclophosphamide) for 79 +/- 9.7 (SE) months. Cumulative survival ratio for 5, 10 and 15 years after enrollment was 0.90, 0.82 and 0.77 and after appearance of first symptoms or signs of kidney disease as determined by anamnestic data 0.97, 0.91 and 0.90 accordingly. Triple-drug therapy (prednisone and azathioprine combined with chlorambucil or cyclophosphamide) was more effective in improving proteinuria than other immunosuppressive regimens. No serious side effects were encountered.

Diagnostic and prognostic value of antibody-dependent cellular cytotoxicity and lectin-induced cellular cytotoxicity tests for renal graft rejection

Peripheral blood lymphocytes from both normal subjects and kidney allograft recipients, before and on the 4th to 5th days after transplantation, were examined for antibody-dependent cellular cytotoxicity (ADCC) and lectin-induced cellular cytotoxicity (LICC). The graft recipients were treated with standard immunosuppression, which included azathioprine and prednisolone. 51Cr-labeled L1210 cells were used as targets for these two tests. ADCC and LICC activity were evaluated in the presence of rabbit anti-L1210 anti-serum and phytohemagglutinin (PHA), respectively. Comparison of the results obtained from healthy subjects with those of patients before grafting showed a significantly higher LICC activity in the latter group. The ADCC activity did not differ between the groups of healthy females and those awaiting transplantation but it was significantly decreased in the group of males awaiting transplantation as compared to healthy males. Four to 5 days after transplantation, the activity of ADCC and LICC remained unchanged in spite of the immunosuppressive treatment in 37 and 61% of the patients studied, respectively. In most of the patients, high ADCC and/or LIcC activity was followed by an accelerated acute rejection episode. A correlation between the ADCC and LICC activities, measured 4 to 5 days after transplantation, and the time of the first rejection episode was found. We conclude that double screening with ADCC and LICC tests in the 1st week after transplantation is valuable.

Triple-drug therapy of chronic glomerulopathies

Prolonged combined treatment with prednisone and immunosuppressive drugs can, if started early enough, significantly reduce the degree of proteinuria and preserve renal function. This is not necessarly associted with simultaneous histological improvement confirmed by renal biopsy. The proposed method of treatment deserve further evaluation.