RENAL HOMOTRANSPLANTATION; LATE FUNCTION AND COMPLICATIONS

Review of the early diagnoses and assessment of rejection in vascularized composite allotransplantation

The emerging field of vascular composite allotransplantation (VCA) has become a clinical reality. Building upon cutting edge understandings of transplant surgery and immunology, complex grafts such as hands and faces can now be transplanted with success. Many of the challenges that have historically been limiting factors in transplantation, such as rejection and the morbidity of immunosuppression, remain challenges in VCA. Because of the accessibility of most VCA grafts, and the highly immunogenic nature of the skin in particular, VCA has become the focal point for cross-disciplinary approaches to developing novel approaches for some of the most challenging immunological problems in transplantation, particularly the early diagnoses and assessment of rejection. This paper provides a historically oriented introduction to the field of organ transplantation and the evolution of VCA.

Recurrent pancreatitis after renal transplantation in a child

A five-yr-old girl, who was a renal transplant recipient, presented with nausea, vomiting, epigastric discomfort, papules, and vesicles on her body. She was diagnosed with acute pancreatitis and varicella zoster infection because her serum amylase and lipase levels were positive. Fourteen months later, she was readmitted with nausea, vomiting, and epigastric pain similar to the previous symptoms and was diagnosed with acute pancreatitis. This case report indicates that acute pancreatitis can be one of a number of complications following pediatric renal transplantation and can recur because of various causes.

Late complications after total hip replacement in renal allograft recipients

Seventy nine hips in 53 recipients of renal allografts were treated by cemented total hip replacement for avascular necrosis of the femoral head between 1972 and 1992. Eight hips in 6 patients required revision for aseptic loosening after a mean of 11.2 years. Three replacements in 3 patients became infected with salmonella enteritidis after a mean of 6.2 years. One was revised, one had a disarticulation of the hip, and the third was treated with long term antibiotics. Survivorship analysis for total hip replacement and the renal allografts showed a hip reoperation rate of 9.9% at 10 years and 54.6% at 15 years with mortality rates of 32.2% and 42.2% respectively. Thus patients surviving 15 years are at a higher risk of failure of the prostheses than of dying.

Osteonecrosis: current perspectives on pathogenesis and treatment

Nontraumatic osteonecrosis results from impairment of circulation to the affected bone. The femoral head is affected most frequently. The underlying cause for the circulatory defect in osteonecrosis varies and may involve both local and systemic changes. Steroid use, alcohol consumption, pancreatitis, and lipid disorders appear to lead to bone death either by development of fat emboli in the microcirculature surrounding the affected bone or by fatty infiltration of the marrow. Decompression syndrome results from the presence of gaseous emboli in the microcirculature. In Legg-Calvé-Perthes disease other associated features are present such as short stature, suboptimal growth velocity, and/or hormonal imbalances, and it is likely that osteonecrosis may be secondary to systemic abnormalities, although specific factors have not been identified. Other frequently suggested pathogenic factors that play a role in the development of osteonecrosis include increased intraosseous pressures, the presence of cytotoxic cellular factors, intravascular coagulation, venous stasis, and the hyperviscosity syndrome. Some investigators have attempted, without success, to find a common etiology for all cases of osteonecrosis. In addition, patients have developed osteonecrosis without any known risk factors; this syndrome has been coined idiopathic avascular necrosis. In advanced stages of femoral head osteonecrosis, total hip arthroplasty appears to be the best therapeutic modality, particularly in older individuals.

Arteriolosclerosis of the human renal allograft: morphology, origin, life history and relationship to cyclosporine therapy

In the decade 1979-1988, 658 biopsies were collected from 568 cadaveric renal allografts. In 118 grafts a non-proliferative insudative vasculopathy (IVA) was found in afferent vessels. Immunosuppression was based on azathioprine (AZA) or on cyclosporin A (CsA), from 1983. The prevalence and extent of IVA has increased significantly since 1984. Light microscopy showed fibrinoid and hyaline masses of varying extent; transmural insudative "knobs", intimal oedema with metachromasia, and microthrombosis were also seen with CsA. The ultrastructure of the insudates was unremarkable but CsA grafts displayed early oedema and hypergranulation of endothelial cells with a disarray of smooth muscle cell (SMC) microfibrils, and pronounced degenerative changes of SMC. Rebiopsy showed stationary IVA in AZA grafts and progression in one-half of CsA-treated patients. Nephrectomy specimens revealed, however, a marked predominance of late rejection endarteritis; in only 3 cases was IVA and/or microthrombosis the possible cause of nephrectomy. The mean donor age was higher in severe IVA in CsA grafts and the mean post-transplantation interval at the time of diagnosis of IVA was significantly shorter in CsA-treated patients. No important differences in cumulative graft survival were seen between grafts with absent, moderate or severe IVA. Unused cadaveric donors' kidneys of comparable age exhibited normal arterioles or a slight focal insudative or hyaline lesion.

Aseptic necrosis of the femoral head following renal transplantation

The occurrence of aseptic hip necrosis was investigated in 546 renal transplant patients (639 transplants) with graft survival for a minimum of 12 months. Aseptic hip necrosis developed in 39 hips in 29 patients (5.3%) from 3 to 121 months (mean 22 months) after the renal transplantation. There was no sex-related difference in incidence of hip necrosis. The complication was significantly more common among patients younger than 20 than among those older than 40 years. The development of hip necrosis did not correlate with type of renal disease, origin of graft (cadaver of living relative donor), side of transplant or length of dialysis treatment. The number of transplantations per patient did not influence the occurrence of hip necrosis. Analyses of serum concentrations of creatinine, calcium, phosphorus and parathormone before and at different periods after transplantation revealed no patterns predictive of hip necrosis. The pathogenesis of aseptic necrosis of the femoral head obviously is multifactorial.

Avascular necrosis of bone complicating corticosteroid replacement therapy

Two patients who developed widespread severe avascular necrosis of bone while on steroid replacement therapy are described. One, a diabetic, underwent yttrium-90 pituitary ablation for retinopathy and developed avascular necrosis within 18 months of starting prednisolone. The other, who had Addison's disease, developed avascular necrosis within 14 months of starting cortisol replacement therapy. Both cases came to bilateral total hip replacement.

Consequences of avascular necrosis of the femoral head in aluminium-related renal osteodystrophy and the role of endochondral ossification in the repair process

A patient with chronic renal failure, a dialysis encephalopathy syndrome and renal osteodystrophy associated with aluminium intoxication developed an avascular necrosis of the left femoral head. Histological examination of the excised head confirmed the zone of avascular necrosis and demonstrated an exuberant formation of cartilage around this zone. Calcification was sparse and the cartilage exhibited histological features similar to those seen in classical rickets. Histochemical and electron probe x-ray microanalysis demonstrated aluminium in the matrix around hypertrophic chondrocytes, at the tide mark of articular cartilage and at the mineralised tissue/osteoid interface of trabecular bone. Aluminium, therefore, preferentially localises at sites of calcification and possibly exerts an inhibitory effect on this reaction. This is taken to account for the relative failure of endochrondral ossification and the development of a rachitic appearance. A comparison with five other examples of avascular necrosis of the femoral head (occurring after renal transplantation, as an idiopathic phenomenon and as a complication of steroid therapy) showed that, in addition to the more commonly described appositional bone formation, cartilage formation and endochondral ossification were present in three of these comparison cases, although less prominent and of considerably less degree than in the main case.

Incidence of later ureteral obstruction after antireflux surgery in infants and children

Forty infants and children who underwent antireflux surgery for primary reflux had long-term follow-up with intravenous pyelograms (IVP). The IVPs were evaluated for the incidence of late ureteral obstruction. Although 4 cases (5.5 per cent) of early ureteral obstruction were noted, no instances of late ureteral obstruction were found. After antireflux surgery, patients should have a follow-up IVP within the first six months to rule out the possibility of early ureteral obstruction. The need for performing periodic IVPs for many years postoperatively, when obstruction is absent in the immediate postoperative period, is questioned.

Hypertension in renal transplant recipients: role of bilateral nephrectomy

Of 81 transplanted kidneys which functioned for six months or more 59 were transplanted to bilaterally nephrectomized recipients and 22 to recipients who retained their own kidneys. There was an excess of hypertension in the non-nephrectomized group (17/22) as compared to 24/59 in the nephrectomized patients, though renal function was better in the non-nephrectomized group. Hypertension became much easier to control in two of the four non-nephrectomized recipients in whom bilateral nephrectomy was performed after transplantation when renal function was good.

5-Fluorocytosine in the treatment of experimental candidiasis in immunosuppressed mice

A model infection with Candida albicans was established in mice. The animals were pretreated for 1 week with azathioprine, given dexamethasone, and then infected intravenously with Candida. Mortality for the group given Candida infection alone was 20%, 38% when azathioprine was added, and 50% when dexamethasone and azathioprine were given with infection. The titers of Candida in most mice were 10(6) per gram of kidney. The rest of the mice were killed at 30 days. At this time, 16% had no evidence of Candida in the kidneys, but 40% of the mice had titers of 10(6) or more. Mice treated with 5-fluorocytosine had a mortality of less than 4% in 30 days. Five percent of the treated mice killed at 30 days had titers of Candida of 10(6). Therefore, 5-fluorocytosine increases survival in the presence of continued therapy with azathioprine with or without pretreatment with dexamethasone. The survival is associated with decreased titers of Candida in the kidneys.

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.

Hypertension following cadaveric renal transplantation

The incidence and aetiology of hypertension following cadaveric-donor renal transplantation have been investigated in twenty-four patients. Initially, the diastolic blood pressure was persistently above 100 mmHg in 52% of the patients. By 1 month after renal transplantation the incidence had fallen to 17% but it then increased rapidly, so that by 5 months 83% had hypertension.

Changes in blood pressure correlated poorly with changes in the dose of prednisone, extracellular fluid volume, exchangeable sodium, creatinine clearance and haemoglobin.

The recipient's original diseased kidneys were removed after transplantation in seven patients. The blood pressure fell to normal levels in three, remained unchanged in two and became easier to control with antihypertensive drugs in the other two patients. Measurements of plasma renin concentration were of no value in predicting the response to recipient nephrectomy.

Urological complications in 216 human recipients of renal transplants

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Transplant lung--a new syndrome

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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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Human cadaveric renal transplantation. Report of twenty cases

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

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Changes in the transplanted ureter

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Histoplasmosis and thrombocytopenic purpura: transmission by renal homotransplantation

Two patients with disseminated histoplasmosis are reported. One patient presented with severe thrombocytopenic purpura and splenomegaly. Histoplasmin skin test, blood and bone marrow cultures and smears, sputum cultures, and chest radiographs were negative for Histoplasma capsulatum. She died on the sixth hospital day from a massive intracerebral hemorrhage. Cardiorespiratory function was maintained until one kidney was removed for homotransplantation. The second patient, with chronic glomerulonephritis and uremia, received the renal homograft from the first patient. Initial signs of homograft rejection developed five days postoperatively. Diffuse thrombocytopenic purpura occurred shortly thereafter. Spores of Histoplasma capsulatum were observed in blood smears, in leukocyte concentrates, and in five-day leukocyte cultures from the blood obtained prior to death. Disseminated histoplasmosis was found in both patients at autopsy. The severe platelet deficit in both cases suggests that systemic histoplasmosis should be considered as a cause of thrombocytopenic purpura.To our knowledge, this is the first reported instance of direct transmission of Histoplasma capsulatum, and must be considered a hazard in homotransplantation.In vitro leukocyte cultures as a method for early diagnosis of certain disseminated fungous infections needs further investigation.