RENAL HOMOTRANSPLANTATION IN 24 PATIENTS

The rejection that defies antirejection drugs-chronic vascular rejection (allograft vasculopathy): The role of terminology and linguistic relativity

While allograft loss due to acute rejection has been dramatically reduced due to the introduction of immunophilins, this therapy has little effect on allografts lost due to chronic vascular rejection. This situation may be due to a misnomer of the pathology. Specifically, its designation as 'chronic rejection' has given the wrong impression that the cause of the disease has been identified. Analyzing this phenomenon under the rubric of linguistic relativity suggests that the words chosen to name the disease may have restricted our cognitive ability to solve the problem. Thus, we have to step out of the 'alloimmunity/rejection box'. Let's pause between our words, Speak and fall silent again, So that the meaning of the word just spoken, Sounds a clearer echo in our heads. Let's pause between our words. Andrey Makarevich.

Accommodation in ABO-incompatible organ transplants

Accommodation refers to a condition in which a transplant (or any tissue) appears to resist immune-mediated injury and loss of function. Accommodation was discovered and has been explored most thoroughly in ABO-incompatible kidney transplantation. In this setting, kidney transplants bearing blood group A or B antigens often are found to function normally in recipients who lack and hence produce antibodies directed against the corresponding antigens. Whether accommodation is owed to changes in anti-blood group antibodies, changes in antigen or a change in the response of the transplant to antibody binding are critically reviewed and a new working model that allows for the kinetics of development of accommodation is put forth. Regardless of how accommodation develops, observations on the fate of ABO-incompatible transplants offer lessons applicable more broadly in transplantation and in other fields.

Metabolic consequences of modern immunosuppressive agents in solid organ transplantation

Among other factors, sophistication of immunosuppressive (IS) regimen accounts for the remarkable success attained in the short- and medium-term solid organ transplant (SOT) survival. The use of steroids, mycophenolate mofetil and calcineurin inhibitors (CNI) have led to annual renal graft survival rates exceeding 90% in the last six decades. On the other hand, attrition rates of the allograft beyond the first year have remained unchanged. In addition, there is a persistent high cardiovascular (CV) mortality rate among transplant recipients with functioning grafts. These shortcomings are in part due to the metabolic effects of steroids, CNI and sirolimus (SRL), all of which are implicated in hypertension, new onset diabetes after transplant (NODAT), and dyslipidemia. In a bid to reduce the required amount of harmful maintenance agents, T-cell-depleting antibodies are increasingly used for induction therapy. The downsides to their use are greater incidence of opportunistic viral infections and malignancy. On the other hand, inadequate immunosuppression causes recurrent rejection episodes and therefore early-onset chronic allograft dysfunction. In addition to the adverse metabolic effects of the steroid rescue needed in these settings, the generated proinflammatory milieu may promote accelerated atherosclerotic disorders, thus setting up a vicious cycle. The recent availability of newer agent, belatacept holds a promise in reducing the incidence of metabolic disorders and hopefully its long-term CV consequences. Although therapeutic drug monitoring as applied to CNI may be helpful, pharmacodynamic tools are needed to promote a customized selection of IS agents that offer the most benefit to an individual without jeopardizing the allograft survival.

ABO-incompatible renal transplantation in developing world - crossing the immunological (and mental) barrier

ABO incompatibility has been considered as an important immunological barrier for renal transplantation. With the advent of effective preconditioning protocols, it is now possible to do renal transplants across ABO barrier. We hereby present a single center retrospective analysis of all consecutive ABOi renal transplants performed from November 2011 to August 2014. Preconditioning protocol consisted of rituximab, plasmapheresis and intravenous immunoglobulin (IVIG) and maintenance immunosuppression consisted of tacrolimus, mycophenolate sodium, and prednisolone. The outcome of these ABOi transplants was compared with all other consecutive ABO-compatible (ABOc) renal transplants performed during same time. Twenty ABOi renal transplants were performed during the study period. Anti-blood group antibody titer varied from 1:2 to 1:512. Patient and graft survival was comparable between ABOi and ABOc groups. Biopsy proven acute rejection rate was 15% in ABOi group, which was similar to ABOc group (16.29%). There were no antibody-mediated rejections in ABOi group. The infection rate was also comparable. We conclude that the short-term outcome of ABOi and ABOc transplants is comparable. ABOi transplants should be promoted in developing countries to expand the donor pool.

ABO Incompatible Kidney Transplantation-Current Status and Uncertainties

In the past, ABO blood group incompatibility was considered an absolute contraindication for kidney transplantation. Progress in defined desensitization practice and immunologic understanding has allowed increasingly successful ABO incompatible transplantation during recent years. This paper focused on the history, disserted outcomes, desensitization modalities and protocols, posttransplant immunologic surveillance, and antibody-mediated rejection in transplantation with an ABO incompatible kidney allograft. The mechanism underlying accommodation and antibody-mediated injury was also described.

The role of ABO-incompatible living donors in kidney transplantation: state of the art

In the past, ABO incompatibility has been considered an absolute contraindication for living donor kidney transplantation. Over the past 25 years, advances in immunosuppressive therapy and progressively more refined desensitization protocols have allowed increasingly successful transplantations across the ABO barrier. Current results of kidney transplants from ABO-incompatible living donors are quite favorable and comparable in the long term with the outcome of ABO-compatible organs both in Japan and in the United States. The present article reviews the history, outcomes, and current issues in kidney transplantation with ABO-incompatible living donors in adult and pediatric recipients.

Persistent cutaneous herpes simplex infection

A 38-year-old, renal transplant patient developed painful, extensive, chancre-like genital ulcerations. The etiological agent was found culturally to be herpes virus type II. The eruption lasted five months and proved recalcitrant to standard therapeutic modalities. On removal of the transplanted kidney and thereby reduction of immunosuppressive agents, the cutaneous viral infection cleared rapidly. The potential severity and persistence of cutaneous herpetic infections in renal transplant patient must be well appreciated or the diagnosis might eaily be missed.

Herpesvirus hominis infections in renal transplant recipients

A longitudinal, prospective study of herpesvirus hominis (HVH, herpes simplex virus) was carried out in immunosuppressed renal allograft recipients using serologic, virologic and clinical techniques. The final study group consisted of 37 patients of which 31 were followed for at least 2 months and 26 for more than 1 year. A 4-fold rise or more in HVH complement-fixing antibody in relation to titers measured at the time of transplantation was found in 11 patients. Eight of these 11 patients had clinically recognizable herpetic lesions. An additional 9 patients had lesions without titer rise being demonstrable. The 20 of the 37 patients studied (54%) had evidence of active infection with HVH. Because of pain and discomfort herpetic sores were of clinical importance in 11 patients and lasted for 1 month or more in 9. Herpetic keratitis was seen in 3 and left permanent damage to sight in 2. Multiple, extensive, prolonged and sometimes destructive herpetic lesions affected 5 (16%) of all patients studied.

Variations in arterial blood pressure after kidney transplantation. Relation to renal function, plasma renin activity, and the dose of prednisone

The course of hypertension within the first 2 months after kidney transplantation was correlated with renal function, plasma renin activity (PRA), and the daily maintenance dose of prednisone in 18 homograft recipients. During acute rejection blood pressure (BP) closely correlated with PRA. Patients with normal homograft function showed an increase in BP early after transplantation which in most returned to normal 3–8 weeks later. In the latter group no correlation could be found between the level of BP and PRA, however the BP correlated closely with the dose of prednisone. These observations suggest that during acute rejection the increase in BP may at least partly be mediated by a renal pressor mechanism, whereas with normal renal function the high dose of glucocorticoids may play an important role in the development of hypertension.

Paraquat poisoning--lung transplantation

A 15-year-old boy ingested a mouthful of paraquat and developed severe respiratory distress. Treatment included the transplantation of one lung, but subsequently changes developed in the graft which are thought to have been due to paraquat, and the patient died two weeks after the operationThe dangers of keeping poisonous substances in incorrectly labelled bottles has once again been demonstrated, while the pattern of paraquat poisoning, especially the development of proliferative alveolitis and terminal bronchiolitis, is confirmed.Immediate forced diuresis followed by haemodialysis is necessary to remove paraquat, thereby perhaps avoiding initiation of the changes in the lungs. The technical feasibility of human lung transplantation has again been demonstrated. It has also been shown that infection does not necessarily pose an insuperable problem, at any rate if, as in the case described, there was no preoperative pulmonary infection in either recipient or donor.

Psychological screening of potential donors in a renal homotransplantation programme

The first human renal homotransplantation was performed in 1936. Recently, with the introduction of improved immuno-suppressive techniques, this operation has been carried out on an increasing number of occasions. The first renal homotransplantation in South Australia was performed in February, 1965. The donor was related by marriage to the patient and was not consanguineous. The patient is still alive and at work sixteen months later (June, 1966).

Transplantation of the kidney

Progress in homotransplantation of the kidney has been reviewed. This form of therapy for the patient with terminal uremia has resulted in a 2-year survival of more than 50% at the University of Colorado Medical Center, excluding from consideration identical twin cases. The best results were with the use of kidneys obtained from familial donors; when this has been possible the 2-year survival is almost ²/₃. With randomly selected non-related living donors the 2-year survival was only 22%.

Although these results indicate the great potential value of organ transplantation, the techniques being employed today are imperfect. The need for progress with better immunosuppression, better histocompatibility analysis, and better organ preservation are outlined.

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

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Chronic survival after human renal homotransplantation. Lymphocyte-antigen matching, pathology and influence of thymectomy

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