Renal allotransplantation in man. II. Transplantation in cystinosis, a metabolic disease

Allogeneic Hematopoietic Stem Cell Transplantation for Inherited Disorders: Experience in a Single Center

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (ASCT) is a possible cure for many inherited disorders.

METHODS

We report 20 years of experience in 71 patients. The disorders include 7 immunodeficiencies, 21 hematological disorders, 13 histiocytic disorders, 9 mucopolysaccharoidoses, 7 metachromatic leukodystrophies (MLD), 3 adrenoleukodystrophies (ALD), 2 adrenomyeloneuropathy (AMN), 6 patients with Gaucher's disease, 1 Sandhoff's disease, and 2 patients with aspartylglucosaminuria. Their median age was 4 (0-39) years. The donors were 29 HLA-identical related, 27 matched unrelated (MUD) and 15 HLA mismatches.

RESULTS

In recipients of HLA-identical sibling grafts, none developed acute GVHD grades II-IV as against 22% in all others. The overall cumulative incidence of chronic GVHD was 17%. The 5-year survival rates were 93%, 84%, and 46% in recipients of grafts from HLA-identical siblings, MUD and HLA-mismatches, respectively. The overall 10-year survival rate was 69%. All of the surviving patients with immunodeficiencies and hemoglobinopathies are well. Four patients with Hurler's disease are also well, apart from skeletal problems. Five patients with Gaucher's disease are between 14 and 22 years after the transplant. Two infants with MLD deteriorated, a girl with the juvenile form has stable disease and one woman with the adult form has improved. Among four survivors with ALD/AMN, three are well and one has dementia. Two patients with aspartylglucosaminuria have stable disease.

CONCLUSION

In patients with inborn errors of metabolism, ASCT gives a high survival rate using HLA-matched donors. Beneficial effects are seen in those who are transplanted early.

Long-term ocular changes in cystinosis: observations in renal transplant recipients

Following renal transplantation in nephropathic cystinosis, an extension of retinopathy associated with a variety of subtle functional ocular abnormalities may occur. However, these abnormalities have not (except for photophobia) been of subjective significance to cystinotic patients. Our data, gathered from patients transplanted as long as nine years ago, indicate that cystinotic patients should not have renal transplant withheld because of the fear of subsequent progressive ocular deterioration.

Cadaver renal transplantation in children with cystinosis

Five children with end-stage renal disease resulting from cystinosis received seven cadaver renal allografts. Four recipients have functioning grafts eight to 55 months after receiving the transplant and one recipient lost two grafts at 17 and 26 months after the transplant. There was no florid recurrence of the Fanconi syndrome although proximal renal tubular dysfunction developed in two patients, in one in association with chronic rejection and in one without apparent etiology. Free cystine content of white blood cells, cultured skin fibroblasts and allograft tissue was significantly increased. Cystine crystals were observed in the mesangium of two grafts and in the interstitial tissue of all grafts; however, no cystine crystals were found in the tubules. The location of the cystine crystals, as well as the fact that the highest free level of cystine of allograft tissue was observed in the graft undergoing chronic rejection. led to the hypothesis that recipient cells infiltrating the graft were the source of cystine deposition. The data indicate that successful cadaveric transplantation does not correct the primary metabolic defect in cystinosis, thereby explaining the persistence of the extrarenal clinical manifestations, such as photophobia and hypothyroidism, after renal transplantation in cystinosis.

Kidney transplantation in patients with end stage congenital renal disease. Report of eighteen cases and review of the Organ Transplant Registry

Eighteen patients with end stage congenital renal disease requiring kidney transplantation constituted 12 per cent of the transplantation recipients at this institution over the past six years. The post-transplantation course in this group was remarkably satisfactory, with a 94 per cent graft survival at three years. In addition, we analyzed survival data from over 9,900 patients in the Organ Transplant Registry and demonstrated that transplant recipients with end stage congenital renal disease have equal or better five year patient survival compared with those with acquired end stage renal disease. Only those patients with adult polycystic disease had a less satisfactory prognosis, probably because of age-related factors. In contrast, there were few statistical correlations between renal allograft survival, age, and original disease.