Treatment of chronic renal failure by transplantation and dialysis: two decades of cooperation

Kidney transplantation in the United Kingdom

The National Health Service (NHS) supplies the majority of health care in Great Britain but is virtually the monopoly provider of high technology and disaster services such as treatment for chronic renal failure or end-stage renal disease (ESRD).

The significance of the monocyte crossmatch in recipients of living-related HLA identical kidney grafts

Monocytes and vascular endothelial cells (VEC) carry a "cell specific" antigen system that has been found to play an important role in the pathogenesis of rejection. In a preliminary study utilizing a standard crossmatch technique with the peripheral blood monocyte as target, recipients of HLA identical living-related grafts who had either pretransplant or who developed posttransplant anti-monocyte antibody, had a high incidence of early graft rejection. This larger study of recipients of HLA identical living-related grafts represents the results of 21 patients from 13 separate transplant centers in the United States. Results from this study seem to indicate a positive monocyte crossmatch represented a degree of sensitization toward donor monocyte antigens which lead to a poor clinical course.

Renal isotransplantation without immunosuppression

Four renal isografts have been performed and all have had satisfactory function for 7 1/2 to 17 2/3 years without prophylactic or therapeutic immunosuppression. Three of these patients originally had glomerulonephritis, and in one there was histologic evidence of recurrent disease, 7 1/2 years after transplantation, without proteinura and without change in renal function. Although this experience is small, it suggests that prophylactic immunosuppression is not appropriate for recipients of renal isografts.

Factors contributing to the declining mortality rate in renal transplantation

Recent modifications and refinements in the management of patients with renal allografts have diminished the mortality rate at our hospital to 2 per cent and 5 per cent at one year for patients receiving kidneys from related and cadaveric sources, respectively. Of 186 receiving transplants since 1974, seven (4 per cent) have died within one year of operation. The incidence of wound infections has been reduced from approximately 25 per cent in 1972 to 2 per cent since 1976 by the use of a single high dose of broad-spectrum antibiotics administered at the time of induction of anesthesia for any surgical procedure. Risk and limitations of immunosuppression have been better appreciated, ultrasound is used more often in the diagnosis of partial obstruction or perinephric fluid collections, and needle biopsy of the transplanted kidney has reduced the morbidity inherent in open biopsy. The contribution of sepsis as a cause of death has declined. The diminishing hazard of renal transplantation has made it an increasingly attractive treatment for end-stage kidney disease.

When should the third renal transplant rejection episode be treated?

Recent reports cite better survival when repeatedly rejecting renal allografts are removed and patients returned to hemodialysis. However, the criteria for graft removal remain undefined; although some reports recommend removing all kidneys undergoing a third rejection. In our series (1968-1973) of 316 patients with technically successful first grafts followed 2(1/2)-8 years, graft survival was inversely related to the number of rejection episodes. One hundred per cent of kidneys without rejection are currently functioning or functioned at the time of death compared to 90% with one rejection, 67.4% with two and 21% with three. However, 40% of kidneys having three rejection episodes functioned longer than one year after treatment of the third rejection episode. In an attempt to determine the predictability of one year graft survival or failure following treatment of the third rejection, a formula was developed that correctly predicted in 33 of 38 (87%) patients. The formula was based on information available prior to treatment of the third rejection episode, and represents an index of baseline renal function (serum creatinine after second rejection episode) and two indices of the severity of rejection episodes (serum creatinine change between the first and second rejection episodes; rapidity of sequential rejection).Following its derivation, the formula was applied to a second group (1974) of 19 patients having had three rejection episodes. The formula correctly predicted one year allograft survival or failure following treatment of the third rejection episode in 68% of these patients. A striking finding of our review was a significant difference in current patient survival between those having no rejection episodes (89%) and those having one or more rejection episodes (65%) (p < .00001). There was no significantly greater long-term curtailment in survival if more than one rejection eipsode was treated. Patients having one rejection eipsode seemed to die from varying causes and at varying time periods. Patients dying after two or more rejection episodes had an increased incidence of deaths due to bacterial infection.

Ultrasound in renal transplantation

Because of important differences in prognosis and treatment, prompt and accurate diagnosis of fever, decreasing function, and pain and tenderness around a renal allograft is crucial for differentiation between acute rejection and other post-operative conditions which may give a similar picture. Ultrasound examinations within 24 hours have been performed on all transplant recipients exhibiting symtoms compatible on all transplant recipients exhibiting symptoms compatible with an episode of acute rejection between September 1973 and June 1976 at the Peter Bent Brigham Hospital. The patients were separated into four groups dependent upon diagnosis by ultrasound; Group I(73 patients); allograft enlargment consistent with acute rejection; Group II (14 patients); dilitation of the collecting system; Group III (14 patients); perinephric fluid collections; Group IV (6 patients); miscellaneous conditions. The accuracy of the ultrasound technique was compared within each group to the results from intravenous pyelography, retrograde pyelography, serial renograms, kidney biopsy and/or surgical exploration. This convenient, non-invasive and reproducible method has been extremely effective in the differential diagnosis of rejection in clinical transplantation.

A 14-year experience with kidney transplantation

Between November, 1962 and August, 1975, 668 kidney transplants were done in 556 consecutive patients at Denver, Colorado. The Denver experience has been divided into 7 periods of time, according to the conditions of care during each period. The results in related transplantation have changed little during the decade beginning in 1966. The results in unrelated transplantation have not materially changed since 1968. The long-term patient survival after related transplantation has been better than after cadaver transplantation. The results of transplantation in 57 children ages 3 to 18 years have been slightly better than the results of adult transplantation.

The outcome of kidney transplantation and the feasibility of improving this therapy with present techniques are limited by our inability to accurately match each patient with the immunologically best donor and by our inability to precisely control the immune system of the recipient. Rejection is still the main reason for graft loss, and sepsis remains the main cause of patient mortality. More specific and less toxic means of achieving graft acceptance are needed before a higher level of patient service can be realized. However, even with the tools now available, thousands of recipients throughout the world have been returned to useful lives.

Renal transplantation: a twenty-five year experience

Boston has played a significant role in the development of renal transplantation. In Boston was performed the first successful isograft between identical twins (1954) the first successful allograft between fraternal twins (1959) and the first successful allograft from a cadaveric donor (1962). An immunosuppressive drug was also described in Boston by hematologists Schwartz and Dameschek (1959) and modified for renal transplantation in dogs (1961) and used for the first time in a human recipient in March 1962. By 1965 renal transplantation had become a clinical reality. Three hundred and ninety-eight of 589 recipients (68%) since 1950 are still alive, a remarkable figure considering that it includes all the earliest experimental transplants. One hundred and ninety-five of 295 (68%) with living-related donor transplants still have functioning allografts; 104/265 (39%) with cadaveric donor transplants have functioning grafts currently. Since 1968 transplants from living-related donors have an 80% one year survival whereas cadaveric donor transplants have approximately a 50% one year survival. Seventy-nine per cent of all one year survivors have had excellent psycho-social rehabilitation.