Pilot evaluation of 15-deoxyspergualin for refractory acute renal transplant rejection

15-deoxyspergualin (DSG) is a novel immunosuppressant which has been shown to be effective in preventing and treating rejection in animal allo- and xenotransplant models. Preliminary clinical studies suggest that DSG is an effective antirejection agent. In our study, 4 patients with biopsy-proven rejection episodes that were resistant to steroid and antibody therapy were then treated with DSG. All 4 rejection episodes responded to DSG therapy and all 4 kidneys continue to function (follow-up 7-15 months). However, 2 patients had additional rejection episodes after DSG therapy. Side effects during DSG treatment were minimal; 1 patient, who had also had multiple courses of antibody, developed a lymphoproliferative tumor 2 months after DSG administration. We conclude that DSG is effective in treating refractory renal transplant rejection episodes. Additional studies are necessary to determine the ideal place for DSG in treating renal transplants recipients with rejection.

The impact of the quality of initial graft function on cadaver kidney transplants

Living unrelated donor (LURD) transplants have immunologic barriers similar to cadaver transplants, yet the outcome is better (1-year graft survival = 96%). One advantage of LURD transplants is that, with the extremely short preservation time, the kidney functions immediately. We studied whether the quality of initial renal function affects the outcome of primary cadaver transplants. We divided 301 non-6-antigen-matched recipients transplanted between 1/1/86 and 8/1/92--who had no graft loss due to hyperacute rejection, primary nonfunction, or technical reasons--into 5 groups based on the quality of initial renal function (serum creatinine level in the first week). We determined patient and graft survival rates for each group. We found that the quality of initial function had a significant effect on patient and graft survival rates. Recipients whose serum creatinine level was < 3 mg/dl on posttransplant day 5 (groups 1 and 2) had better patient and graft survival than either those whose serum creatinine level was > 3 mg/dl on day 7 (group 4) or those who required dialysis (group 5). Because some early dysfunction may be immunologic, we reanalyzed the data excluding patients with percent reactive antibody > or = 15; the quality of initial function in this group had a significant impact on outcome. Similarly, when patients with graft loss due to "death with function" were excluded, the quality of initial function had a significant impact on survival rates. We conclude that the quality of early posttransplant function is an important predictor of long-term outcome. Cadaver recipients with immediate good function have outcomes similar to living donor recipients. Our data suggest that increased effort should be made to improve immediate posttransplant function.

The impact of an acute rejection episode on long-term renal allograft survival (t1/2)

An acute renal transplant rejection episode has been shown to be associated with decreased 1-year graft survival. The impact on long-term outcome is undefined. We studied the impact of an acute rejection episode on t1/2, the time it takes for 1/2 of the grafts functioning at 1 year to fail. Use of t1/2 avoids inclusion of early graft loss to acute rejection or complications of treatment. Since 1/1/86, a total of 653 patients have received a primary kidney transplant and had at least 1 year of function. Recipients were divided by the incidence and timing of rejection: no rejection; 1 rejection within the first year; > 1 rejection, the first episode in the first year; and > or = 1 rejection, the first episode after the first year. A single rejection episode in the first year reduced t1/2 (45 +/- 11 years in those with no rejection vs. 25 +/- 8 years in those with 1 in the first year). Multiple rejections (t1/2 = 5 +/- 11 years) and a first rejection after the first year (t1/2 = 3 +/- 1 years) have a significant effect (P < .05). Both living and cadaver donor recipients with rejection had shortened t1/2. For those with > 1 rejection, the first episode in the first year, and those with > or = 1 rejection, the first episode after the first year, chronic rejection was the predominant cause of graft loss; noncompliance also played a role. We conclude that a single rejection episode shortens t1/2. Those with > 1 rejection, the first episode within the first year, and those with > or = 1 rejection, the first episode after the first year, are at high risk for late graft loss.

Successful long-term outcome with 0-haplotype-matched living-related kidney donors

The waiting list for cadaver kidney transplantation continues to grow. Yet there has been little increase in the number of living-donor transplants. At many centers, willing relatives are turned down as potential donors because of poor HLA ABDR matching with the recipient. It has been our policy to accept the 0-haplotype-match (0-HTM) living-related donor. We studied long-term (6-year) outcome of 0-HTM transplants compared with the outcome of transplants from 1- and 2-HTM recipients and from cadaver donors. Since 1984, 352 adults have received primary living-related renal transplants, and had a minimum of 1 year of follow-up: 92 2-HTM, 216 1-HTM, and 44 0-HTM. In the same period and with the same follow-up, 362 adults have received primary cadaver (CAD) renal transplants. Immunosuppression consisted of cyclosporine, azathioprine, and prednisone (triple therapy) for living-donor and sequential therapy for CAD recipients. ABDR match (mean +/- SD) for 0 HTM was 1.3 +/- 8; CAD, 2.0 +/- 1.6; % peak panel-reactive antibodies (PRA) for 0 HTM was 1.2 +/- 5.3; 1 HTM, 6.7 +/- 20; 2 HTM, 7.5 +/- 21; CAD, 15.5 +/- 30. The percentage of PRA at the time of transplant for 0 HTM was .7 +/- 4.4; 1 HTM, 4.1 +/- 1.6; 2 HTM, 6 +/- 18; CAD, 7.2 +/- 20. While the number of ABDR matches was significantly fewer for 0 HTM than for the other groups, the % PRA at transplant and the peak % PRA were less in the 0-HTM group. Other demographics were not significantly different. Patient survival was significantly lower in the CAD group vs. 2-HTM recipients (P < .05). The living-related grafts had significantly greater survival than the CAD grafts (P < .05), but there was no significant difference between 0-, 1-, and 2-HTM graft survival. The most common causes of graft loss in all groups were death and chronic rejection. In our experience, the long-term graft survivals of 0-HTM and 1-HTM transplants are the same, and both are superior to CAD results, using 0-HTM living-related donor transplants should be continued and encouraged.

Nutrition and growth in pediatric renal transplant recipients

Pediatric renal failure patients undergo similar rates of growth retardation on all forms of dialysis, but appears to be worst in the patients not dialyzed before transplant and on TF. These patients had an average age of 27 months before transplant. Table 1 shows that all groups undergo progressive decline in growth as the interval from diagnosis to transplant increases. This is not affected by the number of calories supplied. Pretransplant TF seems to improve catch up growth after transplant, but we saw no definite effect on growth in the pretransplant period. Renal transplantation uniformly improves growth in this population.

Causes of kidney allograft loss in a large pediatric population at a single center

At our institution, 521 kidney transplants were performed in 429 children (mean age 8.7 +/- 5.6-years) between 1969 and 1991. Of these transplants, 408 were primary, 113 were retransplants, 347 were living related, 171 were cadaver, and 3 were living nonrelated. Immunosuppression consisted of prednisone, azathioprine, and Minnesota antilymphocyte globulin (non-CSA) in 339 patients, total lymphoid irradiation in 8, and, more recently, cyclosporine (CSA) in addition in 168 patients. Average follow-up was 8.8 +/- 6.0 years. Actuarial graft survival in the non-CSA versus CSA groups at 1 year was 77.0% versus 85.7%; at 5 years, 59.6% versus 71.9%. Of 136 non-CSA patients, causes of graft loss at 5 years included: chronic rejection in 55 (40.4%), acute rejection in 27 (19.9%), recurrent disease in 16 (11.8%), technical complications in 8 (5.9%), infectious complications in 4 (2.9%), other causes in 5 (3.7%), and death with a functioning graft in 21 (15.4%). Of 40 CSA patients, causes of graft loss at 5 years included: chronic rejection in 16 (40.0%), acute rejection in 8 (20.0%), recurrent disease in 6 (15.0%), technical complications in 3 (7.5%), other causes in 2 (5.0%), and death with a functioning graft in 5 (12.5%). The causes of graft loss did not significantly differ in the non-CSA and CSA groups. Chronic rejection was the most common cause of graft loss in both groups. Research focusing on chronic rejection is needed to improve graft outcome in pediatric kidney transplantation.

Differences in rejection grading after simultaneous pancreas and kidney transplantation in pigs

Clinical observations suggest that recipients of multiorgan transplants from the same donor can have disparate immunological reactions to each organ. We studied this phenomenon in 36 diabetic (streptozotocin-induced), bilaterally nephrectomized immunosuppressed (cyclosporine, azathioprine, prednisone) pig recipients of simultaneous (same donor) pancreas (bladder drained) and kidney allografts by grading the histological intensity of rejection in biopsies of each organ at defined intervals posttransplant. Graft function was monitored by plasma glucose (PG) and urine amylase (UA) for the pancreas and serum creatinine (Cr) for the kidney. Interstitial rejection was graded as absent, mild, moderate, and severe in, respectively, 8%, 25%, 42%, and 5% of pancreas vs. 4%, 12%, 27%, and 50% of kidney biopsies at 1 week; and 0%, 43%, 29%, and 29% of pancreases vs. 10%, 0%, 30%, and 60% of kidneys at two weeks. Although the distribution of grades was similar in the two organs (P > 0.1), the grade of rejection for each pair at 1 week (n = 24) was discordant in 75% (41% differed by one and 35% by > or = 2 grades) and at 2 weeks (n = 7) in 57% (29% by 1 and 29% by > or = 2 grades). The inability to use the severity of interstitial rejection in one organ to predict the findings in the other is exemplified by the fact that for the two pancreases without interstitial rejection at one week, the corresponding kidney showed moderate or severe rejection, and for the 1 kidney without rejection the corresponding pancreas showed moderate rejection. Vascular rejection grades (absent, mild, moderate, severe) also showed a similar distribution for the pancreas (57%, 30%, 9%, 4%) vs. kidney (56%, 30%, 0%, 13%) at 1 week, and at 2 weeks (57%, 29%, 0%, and 14% for the pancreas vs. 78%, 11%, 0%, and 11% for the kidney) (P > or = 0.64). However, the grading of vascular rejection in organ pairs was dyssynchronous in 51% at 1 week (n = 22) and 29% at 2 weeks (n = 7). No vascular rejection in the pancreas with rejection in the kidney was seen in 5 pairs at 1 week (23%) and 0 at 2 weeks (0%), while no rejection in the kidney with rejection in the pancreas was seen in 5 pairs at 1 week (23%) and 2 pairs at 2 weeks (29%).(ABSTRACT TRUNCATED AT 400 WORDS)

Rejection in single versus combined pancreas and kidney transplantation in pigs

Clinically, the incidence of reversible renal allograft rejection episodes appears to be higher in recipients of simultaneous pancreas/kidney (SPK) than of kidney transplantation alone (KTA); conversely, the rate of irreversible pancreas allograft rejection appears to be higher in pancreas transplant alone (PTA) than SPK recipients. Clinical/histological correlation of graft rejection in these three groups has not been precise. Therefore, we studied the incidence and histological severity of the rejection process in a large animal (pig) model of SPK (n = 36), PTA (n = 31), and KTA (n = 36) allotransplantation. SPK and PTA recipients were made diabetic pretransplant by streptozotocin (150 mg/kg). Pancreas graft exocrine secretions were bladder-drained via a duodenocystostomy for urine amylase (UA) monitoring; endocrine function was monitored by plasma glucose (PG) levels. SPK and KTA recipients underwent native nephrectomy, and renal allograft function was monitored by serum creatinine (CR). Cyclosporine, azathioprine, and prednisone were given in tapering doses from the time of transplantation. Grafts were biopsied weekly to grade histologic severity of interstitial and vascular rejection on light microscopy (LM) and for intensity of T cell infiltration on immunofluorescence. Pancreas graft exocrine function (UA above pretransplant baseline), present in 62% of PTA and 68% of SPK recipients at one week, persisted in only 7% of PTA vs. 64% of SPK pigs at 2 weeks (P = 0.0004). Likewise, pancreas graft endocrine function (PG < 200 mg/dl off insulin) was sustained longer in SPK than PTA recipients (100% vs. 84% at 1 and 91% vs. 27% at 2 weeks; P = 0.0006). However, renal allograft functional survival (serum creatinine < 3.0 mg/dl) was not significantly different (P = 0.471) between SPK and KTA recipients (36% vs. 30% at 1 and 23% vs. 13% at 2 weeks). Graft functional parameters partially correlated with biopsy observations. Pancreas allograft biopsies showed a significantly (P = 0.03 at 1 and P = 0.05 at 2 weeks) lower incidence of moderate/severe interstitial rejection in SPK than PTA recipients (67% vs. 95% at 1 and 57% vs. 92% at 2 weeks); rejection was absent in 8% of SPK and in no PTA biopsies at 1 week. Vascular rejection was moderate/severe in significantly fewer (P = 0.0013 at 1 and P = 0.023 at 2 weeks) SPK than PTA pancreas grafts (13% vs. 37% at 1 and 14% vs. 38% at 2 weeks).(ABSTRACT TRUNCATED AT 400 WORDS)

Evolution of kidney, pancreas, and islet transplantation for patients with diabetes at the University of Minnesota

Transplantation began at the University of Minnesota in 1963. Treatment of diabetes and its complications has been emphasized since 1966, when the first pancreas-kidney transplant was done. Of 3,640 kidneys transplanted by 1992, 1,373 were for diabetic recipients, including 658 from living donors and 715 from cadaver donors. The results progressively improved; since 1984, survival rates of kidney grafts have been similar for diabetic and nondiabetic recipients, with three fourths of the grafts functioning at 4 years. As of 1992, 501 pancreas transplants had been done, including 170 simultaneous with a kidney, 142 after a kidney, and 188 alone for nonuremic diabetic patients; again, the results have improved: by the 1990s, graft survival rates were similar in the 3 recipient categories. Successful pancreas transplants have been shown by our coworkers to stabilize or improve neuropathy and prevent recurrence of diabetic nephropathy in kidney grafts. In an attempt to simplify endocrine replacement therapy, we have done 63 human islet transplants, 34 as allografts for patients with type I diabetes and 29 as autografts after total pancreatectomy to treat chronic pancreatitis. Insulin independence occurs for about 50% of islet autograft recipients. Two recent islet allograft recipients treated with 15-deoxyspergualin have had sustained insulin independence. We anticipate that endocrine replacement therapy by transplantation will become routine for diabetic patients as methods to prevent rejection are refined.

Early versus late acute renal allograft rejection: impact on chronic rejection

We studied the effect of acute renal allograft rejection and its timing on the development of chronic rejection and subsequent graft loss. Between January 1, 1987 and April 30, 1991, 424 patients at the University of Minnesota received a primary kidney transplant (minimum follow-up, 1 year). Patients were subdivided by donor source, presence or absence of acute rejection, and the timing of acute rejection onset (early, < or = 60 days vs. late, > 60 days post-transplant). For living donor (LD) transplant recipients (n = 219), the incidence of chronic rejection is 0.8% in those who had no acute rejection (n = 130), 20% in those with acute rejection < or = 60 days (n = 59) (P < 0.001 vs. no acute rejection), and 43% in those with acute rejection > 60 days (n = 30) (P < 0.001 vs. no acute rejection, P = 0.04 vs. early acute rejection). For cadaver (CAD) transplant recipients (n = 205), the incidence of chronic rejection is 0% in those who had no acute rejection (n = 109), 36% in those with acute rejection < or = 60 days (n = 69) (P < 0.001 vs. no acute rejection), and 63% in those with acute rejection > 60 days (n = 27) (P < 0.001 vs. no acute rejection, P = 0.03 vs. early acute rejection). For both LD and CAD recipients, no grafts have been lost to chronic rejection among those who did not first have at least 1 acute rejection episode. In contrast, 23 patients with acute rejection have had graft loss to chronic rejection. For both LD and CAD recipients, those with > 1 acute rejection episode had significantly more chronic rejection than those with only 1 rejection (P < 0.05). There was no significant difference in the incidence of chronic rejection based on whether the first acute rejection episode was steroid resistant or steroid responsive. We conclude that acute rejection is strongly related to the development of biopsy-proven chronic rejection and subsequent graft loss. Patients undergoing their first acute rejection episode > 60 days (vs. < or = 60 days) have an increased incidence of chronic rejection.

Risk factors for chronic rejection in renal allograft recipients

Chronic rejection is a major barrier to long-term renal allograft survival. Cyclosporine, though effective at reducing graft loss to acute rejection, has had little impact on the incidence of chronic rejection. Between June 2, 1986 and January 22, 1991, 587 kidney-alone transplants (566 patients) were performed, and had been entered into our renal transplant database and had at least 1 year of follow-up: 103 with biopsy-proven chronic rejection (37 living-related donor, 66 cadaver) and 484 without chronic rejection (236 LRD 248 CAD). The 5-year patient survival was 84% for recipients with biopsy-proven chronic rejection vs. 89% without (P = .08). The 5-year graft survival was 31% for recipients with biopsy-proven chronic rejection vs. 81% without (P < .0001). Using multivariate analysis, we determined the impact on the incidence of chronic rejection of these variables: transplant number, age at transplant (< 18 years, 18 to 50 years, > 50 years), gender, human leukocyte antigen matching, peak and transplant panel-reactive antibody, acute rejection episodes, infections (including cytomegalovirus, viral, and bacterial), donor age, and CsA dosage at 1 year (< 5 mg/kg vs. > or = 5 mg/kg). Logistic regression models were fit to the data using a forward stepwise selection procedure. In this analysis, risk factors included an acute rejection episode (P < .001), CsA dosage < 5 mg/kg/day at 1 year (P = .007), infection (P = .023), female gender (P = .042), and retransplant (P = .103). Individual analyses were done for CAD and LRD recipients. For both groups, important variables were acute rejection, infection, CsA dosage at 1 year, and age at transplant. In conclusion, acute rejection, CsA dosage < 5 mg/kg/day at 1 year, and infection are the major risk factors for the development of chronic rejection, suggesting that chronic rejection may be the result of inadequate immunosuppression (acute rejection episodes and low CsA dosage) or the production of inflammatory cytokines (infections).