Comparative results of cadaver and related donor renal homografts in man, and immunologic implications of the outcome of second and paired transplants

Management of de novo nephrolithiasis after kidney transplantation: a comprehensive review from the European Renal Association CKD-MBD working group

The lifetime incidence of kidney stones is 6%-12% in the general population. Nephrolithiasis is a known cause of acute and chronic kidney injury, mediated via obstructive uropathy or crystal-induced nephropathy, and several modifiable and non-modifiable genetic and lifestyle causes have been described. Evidence for epidemiology and management of nephrolithiasis after kidney transplantation is limited by a low number of publications, small study sizes and short observational periods. Denervation of the kidney and ureter graft greatly reduces symptomatology of kidney stones in transplant recipients, which may contribute to a considerable underdiagnosis. Thus, reported prevalence rates of 1%-2% after kidney transplantation and the lack of adverse effects on allograft function and survival should be interpreted with caution. In this narrative review we summarize current state-of-the-art knowledge regarding epidemiology, clinical presentation, diagnosis, prevention and therapy of nephrolithiasis after kidney transplantation, including management of asymptomatic stone disease in kidney donors. Our aim is to strengthen clinical nephrologists who treat kidney transplant recipients in informed decision-making regarding management of kidney stones. Available evidence, supporting both surgical and medical treatment and prevention of kidney stones, is presented and critically discussed. The specific anatomy of the transplanted kidney and urinary tract requires deviation from established interventional approaches for nephrolithiasis in native kidneys. Also, pharmacological and lifestyle changes may need adaptation to the specific situation of kidney transplant recipients. Finally, we point out current knowledge gaps and the need for additional evidence from future studies.

African-Americans with End Stage Renal Disease in the Early Years of Kidney Transplantation

INTRODUCTION

The first successful kidney transplant in humans was performed in 1954. In the following 25 years, the biomedical, ethical, and social implications of kidney transplantation were widely discussed by both healthcare professionals and the public. Issues relating to race, however, were not commonly addressed, representing a "blind spot" regarding racial disparities in access and health outcomes.

METHODS

Through primary sources in the medical literature and lay press, this paper explores the racial dynamics of kidney transplantation in the 1950-1970s in the United States as the procedure grew from an experimental procedure to the standard of care for patients in end-stage renal disease (ESRD).

RESULTS & DISCUSSION

An extensive search of the medical literature found very few papers about ESRD, dialysis, or renal transplant that mentioned the race of the patients before 1975. While the search did not reveal whether race was explicitly used in determining patient access to dialysis or transplant, the scant data that exist show that African-Americans disproportionately developed ESRD and were underrepresented in these early treatment populations. Transplant outcome data in the United States failed to include race demographics until the late 1970s. The Social Security Act of 1972 (PL 92-603) extended Medicare coverage to almost all Americans with ESRD and led to a rapid increase in both dialysis and kidney transplantation for African-Americans in ESRD, but disparities persist today.

Retrograde Intrarenal Surgery Through an Incision of the Ureter as a Good Treatment Option for Large Ureteropelvic Impacted Stones in Transplanted Kidneys

Urolithiasis is a rare complication after kidney transplant. Over the years, treatment of kidney stones has evolved radically, but a standard approach for transplanted kidneys has not yet been defined. Here, we present a 69-year-old male patient who received successful treatment of nephrolithiasis of the transplanted kidney. The patient, who had received a kidney from a deceased donor, was admitted to our department following a posttransplant Doppler ultrasonography showing severe hydronephrosis of the transplanted kidney associated with acute renal function decay. Computed tomography scan confirmed the hydronephrosis of the transplanted kidney, showing a large, impacted, ureteropelvic 3-cm-diameter stone and other concretions around the ureteral stent. The patient was then treated with retrograde intrarenal surgery during an open ureterotomy. His postoperative course was uneventful, and he showed good functional reprise and a rapid decrease of serum creatinine levels. Intraoperative retrograde intrarenal surgery could be a valid option for treatment of kidney stones of the transplanted kidney during open surgery of the ureter or during ureterovesical anastomosis.

Transplants and Psychological Survival in the Treatment of Kidney Disease

In brief, the problems of transplants focus on who gets it, who gives it, and who decides. The preconceptions that impair decision-making and contribute to the ethical controversies will be described here. Because of the writer's recent experience with renal disease (Cutter, 1970), and the longer history of kidney transplants, the content will be restricted to the kidney. However, the intent is to provide a perspective on all current medical efforts to achieve surcease or survival.

Calcineurin inhibitors and immunosuppression - a tale of two isoforms

Organ transplantation is the state of the art for treating end-stage organ failure. Over 25000 organ transplants are performed in the USA each year. Survival rates following transplantation are now approaching 90% for 1 year and 75% for 5 years. Central to this success was the introduction of drugs that suppress the immune system and prevent rejection. The most commonly used class of immunosuppressing drugs are calcineurin inhibitors (CNIs). Calcineurin is a ubiquitous enzyme that is important for T-cell function. With more people taking CNIs for longer and longer periods of time the consequences of calcineurin inhibition on other organ systems - particularly the kidney - have become a growing concern. Virtually all people who take a CNI will develop some degree of kidney toxicity and up to 10% will progress to kidney failure. In the past 15 years, research into calcineurin action has identified distinct actions of the two main isoforms of the catalytic subunit of the enzyme. The α-isoform is required for kidney function whereas the β-isoform has a predominant role in the immune system. This review will discuss the current state of knowledge about calcineurin isoforms and how these new insights may reshape post-transplant immunosuppression.

The ruby anniversary: forty years of publication of Transplantation Proceedings - the first decade: the flowering of immunology and immunogenetics

The fortieth-ruby-anniversary of publication of Transplantation Proceedings chronicles the major developments in this field of expanding scientific and clinical importance. The first decade of publication included seminal findings in immunogenetics of the major histocompatibility complex-HLA-A, -B, -C, and -D-and immunology of induction and expression of alloimmunity from single cell to mammalian organisms. Initial dissections of destructive versus acceptance mechanisms toward allografts revealed cytotoxic versus suppressive/enhancing cell-mediates and humoral vectors. Initial clinical successes revealed technical accomplishments that warranted broader application of this technology as described in the second decade of the Proceedings-the advent of cyclosporine.

Transplant glomerulopathy, late antibody-mediated rejection and the ABCD tetrad in kidney allograft biopsies for cause

To define the relative frequency of phenotypes of transplant glomerulopathy, we retrospectively reviewed the findings in 1036 biopsies for clinical indications from 1320 renal transplant patients followed in our clinics between 1997 and 2005. Transplant glomerulopathy, defined by double contours of glomerular basement membranes (D), was diagnosed in 53 biopsies (5.1%) from 41 patients (3.1%) at a median of 5.5 years post-transplant (range 3.8-381 months). In cases with D, we studied the frequency of circulating anti-HLA alloantibody (A), peritubular capillary basement membrane multilayering (B) and peritubular capillary C4d deposition (C). B was present in 48 (91%) of D biopsies. C4d staining by indirect immunofluorescence was detected in 18 of 50 D biopsies studied (36%). By Flow PRA Screening or ELISA, A was detected in 33 (70%) in 47 D cases with available sera, of which 28/33 or 85% were donor-specific. Class II (13/33) or class I and II (17/33) were more common than class I (3/33) antibodies. Thus 73% of transplant glomerulopathy has evidence of alloantibody-mediated injury (A and/or C), with ABCD and ABD being the common phenotypes in biopsies for cause. The remaining 27%, mostly BD, may be a different disease or a stage in which A and C are undetectable.

Staghorn calculus in renal allograft presenting as acute renal failure

BACKGROUND

Urolithiasis is a rare complication in renal transplant recipients. We report a case of a staghorn calculus occurring in renal allograft, presenting as anuric renal failure with Gram-negative sepsis.

METHODS AND RESULTS

A 48-year-old Caucasian female, with end-stage renal disease due to autosomal dominant polycystic kidney disease, underwent cadaveric renal transplantation in 1986. Sixteen years after transplant, she presented with Gram-negative sepsis with Proteus mirabilis and acute anuric renal failure in the allograft. After undergoing an emergency nephrostomy and treatment of sepsis, a staghorn calculus was subsequently removed by percutaneous nephrolithotomy. Based on the stone analysis and history of urinary tract infections with urease splitting bacteria, the calculus was thought to be infection-induced.

CONCLUSION

Although a rare complication, urolithiasis in an allograft can be associated with significant morbidity. Immediate recognition is critical to restore renal allograft function and to treat associated serious infection in an immunocompromised patient.

Urinary stones following renal transplantation

BACKGROUND

The formation of urinary tract stones following renal transplantation is a rare complication. The clinical features of stones after transplantation differ from those of non-transplant patients. Renal colic or pain is usually absent and rarely resembles acute rejection.

METHODS

We retrospectively studied 849 consecutive kidney transplant patients in The Rogosin Institute/The Weill-Cornell Medical Center, New York who were transplanted between 1980 and 1997 and had functioning grafts for more than 3 months, to determine the incidence of stone formation, composition, risk factors and patient outcome.

RESULTS

At our center, urinary stones were diagnosed in 15 patients (1.8%) of 849 functioning renal grafts for 3 or more months. Of the 15 patients, 10 were males and 5 were females in their third and fourth decade. Eight patients received their transplant from living donors and 7 from cadaveric donors. The stones were first diagnosed between 3 and 109 months after transplantation (mean 17.8 months) and 5 patients had recurrent episodes. The stones were located in the bladder in 11 cases (73.3%), transplanted kidney in 3 cases and in multiple sites in one case. The size of stones varied from 3.4 mm to 40 mm (mean 12 mm). The composition of stones was a mixed form of calcium oxalate and calcium phosphate in 5 cases and 4 patients had infected stones consisting of struvite or mixed form of struvite and calcium phosphate. Factors predisposing to stone formation included tertiary hyperparathyroidism (n = 8), hypercalciuria (n = 5), recurrent urinary tract infection (n = 5), hypocitraturia (n = 4), and obstructive uropathy (n = 2). Many cases had more than one risk factor. Clinically, painless hematuria was observed in 6 patients and dysuria without bacteriuria in 5 patients. None had renal colic or severe pain at any time. There were no changes in graft function at diagnosis and after removal of stones. Five patients passed stones spontaneously and 8 patients underwent cystoscopy for stone removal.

CONCLUSION

Urinary stone formation following kidney transplantation is a rare complication (1.8%). Hyperparathyroidism, hypercalciuria, recurrent urinary tract infection and hypocitraturia are the most common risk factors, but often there are multiple factors which predispose to stone formation. To detect stones and determine their location and size, ultrasonography appears to be the most useful diagnostic tool. Prompt diagnosis, the removal of stones and stone-preventive measures can prevent adverse effects on renal graft outcome.

[Incidence and treatment of urinary lithiasis in renal transplantation]

INTRODUCTION

Urinary calculi is an uncommon complication in kidney transplantation; several stone risk factors are found in transplanted patients, but in most cases there is not a relationship between these risk factors and stone formation. The treatment of these patients is complex due to their both immunosuppressive status and border-line renal function.

MATERIAL AND METHOD

From 1980 to February 2000, 1198 kidney transplant have been performed in our institution. We describe our series consisting in 22 urinary calculi (15 in the graft, 3 in the urether and 4 in the bladder) in 18 patients, including 7 stones detected in cadaveric donor patients.

RESULTS

We performed external shock wave lithotripsy in 7 patients, bench surgery in 4, endoscopic mechanic lithotripsy in 5, open surgery in 1 and observation in 6. Calcium oxalate (mono and dihidrate) was found in 9 of 13 calculi. Metabolic changes were found in 15 of the 18 patients, the most common was hiperuricemia. There were not complications of every treatment applied and 9% of them needed a savage treatment. We found recurrence in 4 cases (22.2%). Now 12 of the patients are stone-free (66.7%) and three have non-significative stones (83.3% without symptoms).

CONCLUSIONS

Detection of renal calculi in cadaveric renal donors is not a reason to refuse the graft for further transplantation. In both renal calculi up to 2 cm and uretheric calculi surgical treatment is assessed as first option. In caliceal stones smaller than 5 mm observations is the best treatment.

Renal function changes over time in adult recipients of small pediatric kidneys. Evidence against hyperperfusion injury

There has been considerable debate regarding the use of pediatric donor kidneys in adults with end-stage renal disease. These small kidneys may not be able to deal with the metabolic demands of the large adult size, and thus pediatric kidneys may be at higher risk of loss due to hyperperfusion injury. To study the impact of small kidney size on renal outcome, we studied two groups of patients. This retrospective review of patients at a single institution compared recipients of pediatric renal transplants (age < 7 years, n = 37) to a matched group of adult-kidney recipients (1:2 ratio, n = 74). The groups were matched for age, sex, diabetic status, HLA type, and duration of follow-up. Primary outcomes of interest were: calculated creatinine clearance at 6 months, 1 year, 2 years, and 3 years after transplantation and evidence of hyperperfusion damage as determined by proteinuria, graft biopsy, and late graft loss due to chronic rejection. This study demonstrates no significant difference in calculated creatinine clearance between pediatric and adult transplants at 6 months (43.8 vs. 50.7 ml/min, respectively) or at 3 years after transplantation (56.3 vs. 56.2 ml/min), nor was there any evidence of increased proteinuria or late graft loss in the pediatric-kidney recipients compared with adult-kidney recipients. Our data do not demonstrate the detrimental effects of small kidney size relative to recipient on subsequent renal outcomes, and thus support the practice of pediatric donor kidneys being used in adult recipients when pediatric recipients are not available.

Pregnancy outcome in renal allograft recipients: influence of ciclosporin A

The outcome of 35 pregnancies in 26 renal allograft recipients is reported. Twenty-four pregnancies in patients treated with prednisolone and azathioprine resulted in 22 live-born infants (one twin pregnancy) and 3 induced abortions on medical indications. Three of the deliveries were preterm, and one of the infants had a birth weight below the 2.5th percentile. Ten patients (11 pregnancies) were treated with ciclosporin A (CsA). These women delivered 5 infants (3 preterm deliveries of whom the birth weight of one infant was below the 5th percentile) and underwent 3 induced (medical indications) and 3 spontaneous abortions. Mean birth weight in the CsA treated group was 2464 g (range 1790-2930 g), and their gestational age varied from 232 to 271 days. No foetal malformations were observed in the two groups. The results may indicate a harmful effect of CsA on pregnancy outcome.

Dialysis, transplantation, and pregnancy

Women on regular dialysis are usually infertile, but contraception should not be neglected. Pregnancy is invariably complicated and poses excessive risks, with an uncertain and low chance of success. Even when therapeutic abortion is excluded, the live birth outcome at best is 19%. Renal transplantation usually reverses abnormal reproductive function and comprehensive pre-pregnancy counseling is essential, with discussion of all implications, including the harsh realities of long-term maternal survival. In this survey of 2,309 pregnancies in 1,594 women, therapeutic abortion was undertaken in 27% of conceptions and the spontaneous abortion rate was 13%. Of the conceptions that continued beyond the first trimester, 92% ended successfully. In most, renal function was augmented in pregnancy, with transient deterioration in late pregnancy (with or without proteinuria). Permanent renal impairment occurred in 15% of pregnancies. There was a 30% chance of developing hypertension, preeclampsia or both. Preterm delivery occurred in 50%, and intrauterine growth retardation in 25% of pregnancies. Despite its pelvic location, the transplanted kidney rarely produced dystocia and was not injured during vaginal delivery. Cesarean section should be reserved for obstetric reasons only. Neonatal complications include respiratory distress syndrome, leukopenia, thrombocytopenia, adrenocortical insufficiency, and infection. No predominant or frequent developmental abnormalities have been described and data on infancy and childhood are encouraging. For the future more work is needed to improve pre-pregnancy assessment criteria, to understand the mechanisms of gestational renal dysfunction and proteinuria, to assess the side effects and implications of immunosuppression in pregnancy, and to elucidate the remote effects of pregnancy on both renal prognosis and the offspring.

Profound suppression of lymphocyte function in early biliary obstruction

The blastogenic response to mitogens was studied in spleen and lymph node cells from four groups of Lewis rats at 1 to 2, 3 to 5, 6 to 9 and 10 to 14 days, respectively, after common bile duct ligation (CBD) or sham celiotomy (SC). Suppression in the splenocytes' mitogenic response to concanavalin A and phytohemagglutinin was noted as early as 3 days after common bile duct ligation. The response remained suppressed during the period of observation. Lymph node cells manifested a suppressed response to concanavalin A and phytohemagglutinin after 4 days of jaundice. No alteration in splenocyte response to lipopolysaccharide was observed. There was no correlation with the level of serum bilirubin.

Nonhepatitis B-associated liver disease in a renal transplant population

The spectrum of liver disease in a population of 293 patients receiving 353 renal transplants (1971-1984) was reviewed. This study looked retrospectively at the histological features of liver disease in this population, and prospectively at the clinical and biochemical features of liver disease associated with renal transplantation. In all patients, infection with hepatitis B was excluded. Six deaths, primarily attributable to hepatic failure have occurred: one, acute herpes simplex infection; one, subacute massive hepatic necrosis of uncertain etiology; two, pretransplant liver disease; and two, posttransplantation cirrhosis of uncertain etiology. Review of the hepatic histology of 26 patients with known liver disease following transplantation revealed a wide range of pathologies with few specific correlations with their clinical status or biochemical tests of liver function. The prevalence of hepatic dysfunction following transplantation in our patient population was assessed by prospective biochemical screening of 111 transplant recipients over a 6-month interval. During this time period, 27 patients (24%) displayed biochemical evidence of hepatic dysfunction. Liver disease was known to have predated transplantation in only three of 27. Episodes of abnormal liver function occasionally occurred during an identifiable acute illness (six of 27), although the majority (21 of 27) had chronic hepatic dysfunction. Transplant recipients with abnormal liver function could not be differentiated from a cohort with normal liver function on the basis of age, sex, duration of graft function, or alcohol/drug intake. The possible etiologies of nonhepatitis B liver dysfunction following renal transplantation are discussed, and the high prevalence of biochemical evidence of hepatic dysfunction in this population free of hepatitis B infection is emphasized.

A model for thermal gradients during renal vascular anastomoses

Quantitative knowledge of warm ischemic intervals is of special importance in organ transplantation. Warm ischemia as a function of time is deleterious to tissue survival. In a laboratory model of a preserved transplantable organ, we determined thermal gradients in pig kidneys similar in size to human kidneys. Sixteen nonviable porcine kidneys cooled to 0 degrees C were placed in an artificial "iliac fossa." The posterior renal wall was in contact with the normothermic fossa. The anterior renal wall was exposed to the ambient temperature of the "operating room." The temperature of both walls was monitored for a minimum of 2 hr. Temperature changes relative to time and kidney weight were studied. The temperature of the posterior wall rises above 20 degrees C within 5 to 10 min; the anterior wall attains this temperature within 30 to 40 min. The thermal gradient between the two walls is significantly greater for larger kidneys (200 g) than for smaller kidneys (100 g). Implications for biochemical pathology are discussed.

Does cyclosporine influence the results of cadaver retransplantation?

The results of cadaveric retransplantation in 55 recipients immunosuppressed with cyclosporine and prednisone were compared to 156 recipients of primary renal allografts. By 3 yr posttransplant, there is no significant difference in patient survival, but the yearly graft survival for primary (79%, 72%, 72%) as compared to retransplant (69%, 58%, 58%) recipients was significantly (p less than 0.05) better. There was no significant difference in rejection episodes or mean +/- SD serum creatinine (mg/dl) at 2 yr between primary (32%, 2.14 +/- 1.1) and retransplant (33%, 2.08 +/- 1.4) patients, respectively. Donor source, third kidneys, human leukocyte antigen AB and Dr matching, percent reactive antibody levels, and cause of first graft loss do not have significant impact on cyclosporine-treated retransplant outcome. However, retransplant patients who have lost a previous graft in less than 3 months continue to be at high risk for subsequent early graft loss. These results suggest that the combination of cyclosporine and prednisone is the preferred regimen for cadaveric retransplantation.

Why do secondary cadaver renal transplants succeed? Results of the South-Eastern Organ Procurement Foundation prospective study, 1977-1982

We report the selective and therapeutic factors affecting multiple kidney transplant success from a prospective multicenter study of the South-Eastern Organ Procurement Foundation. From June 1977 to March 1982, 3,215 cadaver kidney transplants were performed at 39 institutions. There were 2,535 first, 564 second, 103 third and 13 fourth grafts. The actuarial graft survival rates at 1 and 2 years were 52 plus or minus 1 and 45 plus or minus 1 per cent, respectively, for first grafts, 44 plus or minus 2 and 40 plus or minus 3 per cent for second grafts, and 42 plus or minus 5 and 31 plus or minus 6 per cent for third grafts. Graft survival rates were significantly lower for second and third than for first transplants (p less than 0.003). There was no difference in patient survival rates. The data were analyzed to determine which selective and therapeutic variables governed success of primary and secondary grafts. Pre-transplant blood transfusions were associated with a significant increase in graft survival rates in primary (p less than 0.00005) and secondary transplants (p less than 0.01), and did not affect patient survival rates. The administration of antilymphocyte serum also improved graft survival rates significantly in primary (p less than 0.00005) and secondary grafts (p less than 0.00002), without alteration of patient survival rates. HLA compatibility improved primary graft survival rates (p less than or equal to 0.022) but this did not reach statistical significance in secondary graft survival rates. Second transplant graft survival rates were best when the primary graft functioned for more than 12 months (Breslow p less than or equal to 0.02) but were not related to the reason for loss of the first graft. Pre-transplant bilateral nephrectomy improved graft survival rates significantly but this phenomenon was linked to other treatment factors. No beneficial effect on graft survival rate could be shown after pre-transplant splenectomy in patients with primary or secondary grafts and this procedure was associated with reduced patient survival rates in both groups.

Successful pregnancies in women treated by dialysis and kidney transplantation. Report from the Registration Committee of the European Dialysis and Transplant Association

The Registry of the European Dialysis and Transplant Association collected information on 120 successful pregnancies in women treated by dialysis and transplantation in 19 countries. Ninety-seven women with transplants gave birth to 110 babies including five multiple pregnancies. The incidence of severe congenital malformation in these children was not substantially increased. There was evidence of damage to the transplant occurring either during or after pregnancy in 22 of the mothers. Sixteen successful pregnancies occurred in women on dialysis, all of whom had some residual renal function.

Effect of splenectomy on first cadaver kidney transplants

A prospective study was begun in January 1975 to evaluate the effect of splenectomy on graft and patient survival in recipients of first cadaver kidney transplants. Ninety-two cases were evaluated. Splenectomy increased the survival of both grafts and recipients. The benefit from splenectomy compensated readily for the perioperative morbidity of splenectomy and the long-term increased risk of sepsis from certain bacteria for the asplenic patient. Splenectomy exerted its effect by reducing the incidence and intensity of rejection episodes. It was not clear whether the observation resulted from a direct immunosuppressive effect of splenectomy or from the increased tolerance to azathioprine observed in asplenic recipients. Finally, splenectomy negated an effect of race that had been observed earlier for survival of cadaver transplants and recipients.

Urolithiasis after kidney transplantation--clinical and mineralogical aspects

Urolithiasis is a rare complication following kidney transplantation. Experience with this complication in 6 of 426 transplantations performed from 1968 to 1979 is reviewed. The clinical symptoms are different from the disease in non-transplant patients. Three major predisposing causes for the development of calculi after kidney transplantation were found in our patients--urodynamic disorders following complications of the ureterovesical anastomosis, persistent bacteriuria and renal tubular acidosis and, less importantly, the presence of hypercalcemia and hypercalciuria as a result of secondary hyperparathyroidism. Crystal-optical and x-ray-diffraction studies contributed to the interpretation of the constituents and texture of the calculi and of the aetiological factors concerned.

Thoracic duct fistula and renal transplantation

Thoracic duct drainage (TDD) was established for 21-115 days in 40 kidney recipients with an average removal per patient day of 4.7 1 lymph and 1.88 billion cells. Cellular and humoral immunity were depressed. TDD and immunosuppressive drugs were started at transplantation in 35 recipients of cross-match negative grafts. Although the results were better than in precedent non-TDD controls, eight patients rejected their grafts before a full TDD effect, and three of the eight developed predominantly anti-B lymphocyte cytotoxic antibodies which were probably responsible for positive cross-matches with their next donors. With continuing TDD, all eight patients had good initial function after early retransplantation. In five more "nontransplantable" patients with performed cytotoxic antibodies, TDD was started 30-56 days before transplantation. In these five pretreated patients, antibodies persisted with positive antidonor cross-matches. Hyperacute rejection occurred repeatedly in two patients with high anti-T (and anti-B) titers, but was surmounted in three patients with lower titers. From the clinical and immunologic data, we have concluded that TDD should be used for pretreatment of all cases with or without prior antibodies, and have suggested an adjustable management plan that takes into account new developments in antibody monitoring.

Renal retransplantation in children

Evaluation of 75 cadaver donor retransplants revealed that the primary factor influencing allograft survival is patient responsiveness as reflected by sensitization with preformed cytotoxic antibodies. Actuarial allograft survival rates for nonpresensitized (less than 5%) and moderately presensitized (5 to 50%) recipients were significantly (P less than 0.01) better than those of highly presensitized (greater than 50%) recipients. Although HLA A&B antigen histocompatibility did not have a statistically significant effect on retransplant outcome, it appeared to influence allograft survival in the highly presensitized recipient. An approach to the management of children who lose an initial or subsequent allograft is indicated by these data.

Jaundice after renal allotransplantation

Of 567 patients receiving renal transplantation at the University of Minnesota between October 1967 and October 1975, 22 developed clinical jaundice. Of these 22, nine died with their initial episode of hepatitis, six died within three months of causes associated with liver malfunction, four developed evidence of chronic hepatic failure and only three totally recovered from their illness. Five had clear evidence of Australia antigen positive hepatitis B, four of cytomegalovirus hepatitis, two of herpes hominis hepatitis, one of varicella zoster hepatitis and three of hepatic failure associated with systemic bacterial and/or fungal sepsis. Two of the 22 patients were thought likely to have cytomegalovirus hepatitis though definite proof was absent and in five patients a clear-cut etiology could not be made. In many of these patients the diagnosis was confounded by the previous presence of HB(s)Ag antigen and the frequent occurrence of a previous or concurrent infection with cytomegalovirus. The role of various drugs including azathioprine, sulfisoxazole, chlorpromazine, acetominophen, etc., could not be established but major roles for these agents in the face of the many viral and bacterial infections present in these patients is doubted. No clear-cut therapy could be established although it appears safe to discontinue azathioprine for longer or shorter periods of time with or without substitution of cyclophosphamide without serious deterioration of renal function. The problem of hepatic failure in transplant patients is still unsolved and will require a prospective study of etiologic agents and sub-clinical hepatic dysfunction in order to establish even the first principles of clinical-pathological correlation.

Urinary tract calculous disease after renal transplantation

We report 3 cases of a series of 372 (0.8 per cent) renal transplant recipients in whom urinary tract calculi developed as a complication of the procedure. In each patient symptoms were minimal and not classic of calculous disease. We disagree with the contention that all such patients have either hypercalcemia, infection, or tubular acidosis, although thorough evaluation is indicated. We believe this entity should be considered in problematic renal transplantation patients. Conservative therapy is advocated when the situation permits.

Calculi in renal transplants

Three patients who underwent live donor renal transplantation subsequently developed calculi in their allografts. Hypercalcaemia and secondary hyperparathyroidism were present in 2 cases and these were treated by subtotal parathyroidectomy. Urinary stagnation and infection were contributory factors in the third case and reimplantation of the ureter was necessary. In all patients no further calculi have developed following treatment and allograft function remains satisfactory.

Kidney stones and renal transplantation

Only 10 cases of renal calculi in transplanted kidneys are reported in the literature. Etiology is not uniform in all the cases. Some of these cases were managed conservatively. We herein report a case in which the etiology of the stone may be urinary tract infection. This patient was managed conservatively.

Ruptured human renal allograft. Pathogenesis and management

From January, 1963, to January, 1977, 4 cases of acute allograft rupture occurred in 474 renal transplants performed at the Cleveland Clinic, an incidence of 0.8 per cent. Rupture developed between the fifth and sixteenth day after transplantation during a period when the patients required dialysis because of poor allograft function. All patients had surgical exploration and successful repair of the laceration. Biopsies in each case at the site of laceration revealed findings consistent with acute allograft rejection. The rejections were mild in 2 cases, moderate in one, and severe in another. Two kidneys failed to sustain function, and the patients were returned to chronic hemodialysis two to five months later. None required a nephrectomy. The other two kidneys are functioning well, with serum creatinine values of 1.3 and 1.5 mg./100 ml. one year after allograft rupture. Since rupture of a renal allograft does not appear to increase the intensity of rejection nor does it represent a severe type of rejection, transplant nephrectomy can be avoided unless hemorrhage is uncontrollable from the site of laceration.

Factors in the differential rate of arteriosclerosis (AS) between long surviving renal transplant recipients and dialysis patients

In this study, the incidence of clinical and autopsy arteriosclerosis (AS) was studied in over 300 renal transplant patients (RTP) followed in our clinic up to 13 years post-transplant. Of 45 RTP followed a mean of 10.45 years, the incidence of clinical AS was 6% or 0.58% per year at risk. The incidence of death from AS was 2.2% over 10 years or 0.22% per year at risk. There was no apparent tendency for increase of the risk incidence with increasing time post-transplantation up to 13 years. This incidence of clinical and death-related AS in long term RTP contrasts sharply with a quite high incidence of both clinical and death-related AS in long-term dialysis patients as reported by Scribner's group and both the European and U.S. Dialysis Registry. Of our RTP surviving a decade or more, 77% have normal serum triglycerides and 92% are normotensive, again contrasting sharply with a 70-80% incidence of hyperlipidemia and a 60-80% incidence of hypertension in long-term dialysis patients. These studies suggest that the high rate of accelerated AS in dialysis patients is largely reversed by successful renal transplantation, probably due to a lowering of both blood pressure and hyperlipidemia in the long-term RT patients. Practically, these results suggest that the superior survival of transplant patients over dialysis patients already evident at 10 year mark will widen further during the second post-transplantation decade.

Recurrent glomerulonephritis in human renal homografts

Recurrent glomerulonephritis in kidneys transplanted to glomerulonephritic recipients is becoming more obvious. It has been suggested that the disease process which caused the original disease in the recipient is also operative in the transplanted tissue. This study compared the ultrastructure and immunofluorescence of the native kidneys of four patients with their respective sequential, transplant biopsies. In each case, subepithelial humps and IgG, characteristic of a complex type of nephritis, were observed in both the original diseased kdineys and in the transplants. This would indicate that the immunopathologic process which caused the original glomerulonephritis and led to transplantation is also operative in the transplanted tissue.

Hypercalcemia of seven years' duration after kidney transplantation

A case is reported of hypercalcemia persisting for seven years after kidney transplantation, with normocalcemia being achieved after subtotal parathyriodectomy. The finding of post-transplantation hyperparathyroidism of this extreme duration, in association with several other reports of hyperparathyroidism persisting for years after kidney transplantation, raises serious questions about the completeness of parathyroid involution after kidney transplantation. Extensive review of the literature reveals that little is really known about the natural history of parathyroid function and involution after kidney transplantation.

Nephrolithiasis and nephrocalcinosis after renal transplantation: a case report and review of the literature

Stone formation in renal allografts is rare. Although infection or renal tubular acidosis can predispose to calcium deposition in a renal allograft, hyperparathyroidism is usually an accompanying factor. Parathyroidectomy is recommended as the treatment of choice when stone deposition or nephrocalcinosis occurs after transplantation. The reported case demonstrates that aggressive therapy is also necessary to eliminate calculi from the urinary system to avoid mechanical obstruction, continued infection or renal paraenchymal damage.