CT and Angiography in Adrenocortical Carcinoma

CT and angiography were performed in 15 patients with adrenocortical carcinoma. The tumors had a mean diameter of 11 cm (range 4–20 cm). At CT, the 8 largest tumors were ill-defined, and in these, the organ of tumor origin could not be established. Angiographically the correct organ of tumor origin was established in all but one patient. It is concluded that CT is excellent in showing the extent of an adrenal tumor, but is often unable to predict the organ of origin in large tumors. Angiography is still of great value in the preoperative work-up in patients with large adrenocortical carcinomas for correct identification of tumor origin and for vascular mapping.

Calcineurin inhibitor-free immunosuppression in renal allograft recipients with thrombotic microangiopathy/hemolytic uremic syndrome

Thrombotic microangiopathy (TMA) and hemolytic uremic syndrome (HUS) represent serious threats to kidney allograft recipients. During a 4-year period, among 850 kidney transplantations, seven recipients with primary HUS and seven recipients (eight transplants) with previous or de novo TMA/HUS were identified and given calcineurin inhibitor (CNI)-free immunosuppression by sirolimus (SRL), mycophenolate mofetil and steroids. Thirteen out of 15 transplantations were successful in the long term; resulting in a mean creatinine of 101 mumol/L (16.4 months follow-up). In patients maintained on CNI-free regimen, no TMA/HUS recurrences were observed. A high rate of acute rejections (53%) may indicate insufficient immunosuppressive power and/or a causative relationship between TMA/HUS and rejection. Wound-related complications were abundant (60%), and call for surgical/immunosuppressive countermeasures. Our experience supports the idea that CNI's are major offenders in TMA/HUS induction. Total CNI elimination seems essential, as the nephrotoxic combination CNI + SRL may promote TMA. Features of TMA/HUS should be carefully explored in recurrent 'high responders'.

Effect of fluvastatin on acute renal allograft rejection: a randomized multicenter trial

BACKGROUND

Statin therapy has been reported to reduce the acute rejection rate following renal transplantation in a pilot study. The present study is the first randomized, double-blind and adequately powered study to examine the effect of statins on acute rejection of renal allografts.

METHODS

A total of 364 patients were randomly assigned to receive either fluvastatin 40 mg or placebo in combination with conventional cyclosporine-based immunosuppressive therapy. The primary end point was treated first acute rejection. Secondary end points included biopsy-proven rejection, histological severity of rejection, occurrence of steroid-resistant rejection, and serum creatinine at three months following transplantation.

RESULTS

Fluvastatin was well tolerated; no patients developed myositis or rhabdomyolysis. There was no difference in the acute rejection rate [86 (47.3%) fluvastatin vs. 87 (47.8%) placebo] and no significant difference in the severity of rejection, steroid resistant rejection or mean serum creatinine at three months (160 micromol/L vs. 160 micromol/L). Total cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol and triglyceride levels increased following renal transplantation. With the exception of the increase in HDL-C, which was augmented, the increases in lipid parameters were significantly reduced by fluvastatin (total cholesterol +17.5% vs. 35.7%; LDL-C +6.3% vs. 46.7%; HDL-C +43.3% vs. 38.1%; triglyceride +52.2% vs 77.6%).

CONCLUSIONS

Contrary to the reported effects of statins, fluvastatin had no effect on the incidence or severity of acute rejection following renal transplantation. There were no increases in adverse events. A significant and potentially beneficial alteration in the lipid profile was observed in the early post transplant period. We conclude that fluvastatin may be used safely to correct dyslipidemia in patients with end-stage renal failure through the peri-transplant period.

The role of HLA matching in renal transplantation: experience from one center

The influence of serology-based HLA matching on the risk of acute rejection episodes and of graft loss was analyzed in a material of 678 living donor (LD) and 997 cadaveric donor (CD) renal transplantations performed in our center in the period 1989-97. In LD transplantation, recipients of HLA-identical sibling grafts had the lowest rejection risk and the best graft survival, with a half-life estimate of 30 years. One-HLA-haplotype mismatched grafts did better than two-haplotype mismatched related or unrelated donor grafts. Matching for HLA-DR significantly reduced the rejection risk of one-haplotype mismatched grafts. In CD first transplants, HLA-DR matched grafts had a lower incidence of rejection and better survival than HLA-DR mismatched grafts. Expected half-life for HLA-DR matched grafts was 12 years compared to less than 7 years for HLA-DR mismatched grafts. The effects of matching for HLA-A and -B did not reach statistical significance. In CD regrafts, a two-antigen mismatch for HLA-A or -DR led to a significantly poorer graft survival, but the panel-reactive antibody (PRA) status of the recipient was the most influential factor. In CD renal transplantation, we conclude that organ allocation based on matching for HLA-DR 1-14 is effective and not too difficult to obtain even in centers with a short patient waiting list.

Intracerebral abscess caused by Nocardia otitidiscaviarum in a renal transplant patient--cured by evacuation plus antibiotic therapy

We present a 50-year-old female who experienced generalized convulsion 3 months after a successful cadaveric renal transplantation. The first cerebral CT scan indicated cerebral frontal infarction. Repeat CT some days later revealed progressive lesions, and a highly malignant tumor or abscess was suspected. Antifungal and broad-spectrum antibacterial therapy was initiated. Cerebral MRI could not differentiate between these conditions, but a neutrophil granulocyte scan strongly suggested an infectious process. A stereotactic puncture of the frontal lobe was followed by temporary improvement. A severe progressive left-sided hemiparalysis gave indication for a craniotomy with evacuation of the abscess 9 days later. Culture of aspirated pus yielded growth of a gram-positive, rod-shaped bacterium, later identified as Nocardia otitidiscaviarum by sequencing the 16S rRNA. The patient was treated with meropenem plus rifampicin intravenously for 6 weeks followed by oral ciprofloxacin and rifampicin for 2 months. Due to pharmacokinetic interaction with rifampicin, the prednisolone dose was doubled, and the dose of tacrolimus had to be tripled for maintenance of adequate trough concentrations. Five months following cessation of antibiotic treatment, the patient has regained normal strength and function in her left-sided extremities and has a serum creatinine level of about 160 micromol/l (1.8 mg/dl).

[How to improve the rate of organ donation for transplantation?]

Increasing shortage of organs for transplantation is a global phenomenon. In spite of a high kidney transplantation rate (45 per million population), the waiting list for kidney transplantation in Norway increased by 22% from 1996 to 1998. The waiting list for lung transplantation increased by 129% in the same period. The average annual number of cadaveric organ donors was 15.8 per million, with significant differences in donation rate between the health regions. Investigators have established the incidence of potential organ donors to be around 50 per million population per year. Failure to identify or support a potential donor and refusal of permission from relatives are important reasons why organ donation does not occur. We give a brief overview of programmes implemented in various European countries to increase organ donation. Improvement of donor hospitals organisation in order to support potential donor detection as well as training and motivation of hospital staff are considered important steps for increasing the organ donation rate.

Scandiatransplant: thirty years of cooperation in organ transplantation in the Nordic countries

The Nordic organ exchange organization, Scandiatransplant was established in 1969. The organization, which covers a population of 23.9 million inhabitants, includes all 11 organ transplant centers in the 5 Nordic countries Denmark, Finland, Iceland, Norway and Sweden. The economy is solely based on transplant center fees. All Nordic patients waiting for an organ transplant are registered on one common waiting list. Rules for the exchange of organs are settled by unanimous decision, and the compliance to the rules is excellent. Kidney exchange is based on HLA matching, whereas the exchange of livers and hearts is based on clinical urgency. In 1997, 43% of the liver transplantations in Scandiatransplant were performed with an exchanged organ and the exchange rate for kidneys was 20%. Currently, the Scandiatransplant waiting list includes 1,538 patients waiting for a kidney transplant, 20 patients are waiting for a liver, 37 for a heart, and 156 patients are waiting for a lung transplant. The organ donation rate in Scandiatransplant has declined in recent years, from 16.0 per million population (PMP) in 1993 to a level of 13.5 PMP in 1997. The number of kidney transplants has varied between 800-900 per year during the past 10 years, corresponding to 33-38 transplants PMP. Approximately 30% of the renal transplants were performed with kidneys from living donors. The liver transplantation activity was approximately 7 PMP per year. Heart transplantation was performed at a rate of 4-5 PMP per year, and lung transplants at 4 PMP per year.

The national kidney transplant program in Norway still results in unchanged waiting lists

1. Of 2,670 patients starting renal replacement therapy for end-stage renal disease in Norway from 1989-1997, 76% were candidates for transplantation. The annual need for transplantations increased from 47 to 64 grafts PMP as the number of elderly patients increased. The national waiting list has remained almost stable during the period from 1989-1997 at levels of 25-30 PMP, but the dialysis population has increased from 57-105 PMP. 2. A total of 1,681 transplants was performed at an annual rate varying between 38 and 46 grafts PMP. The grafts were procured from LDs in 41% and CDs in 59% of cases. Totally 69% of all patients in need were transplanted and 54% of all patients requiring replacement therapy for end-stage renal disease received a transplant. 3. Graft survival rates in recipients of first LD grafts (n = 641) were 91% and 77% at one and 5 years, respectively. One-year graft survival was 97% in HLA-identical grafts (n = 71), 92% in haploidentical grafts (n = 419), 88% in 2 haplotype-mismatched related grafts (n = 43), and 87% in spousal donor grafts (n = 108). 4. Graft survival rates in recipients of first CD grafts (n = 801) were 84% and 65% at one and 5 years, respectively. The rates were 86% and 74% in younger (n = 557) versus 78% and 46% in older (> 65 years) (n = 244) patients. Death with a functioning graft caused approximately 45% and 75% of all graft losses in younger and older patients, respectively. Cardiovascular disease was the major cause of death. 5. A significant beneficial effect of HLA-DR matching was observed in CD grafts performed after 1989, in particular in patients older than age 65.

[Pancreas transplantation--a review]

According to the International Pancreas Transplant Registry, more than 1,000 pancreas transplantations are now performed annually. When performed simultaneously with a kidney transplant, pancreas transplantation is a generally accepted treatment for type 1 diabetic patients with end stage renal disease, and the pancreas graft survival in this setting is equivalent to that of the kidney graft. The reported results of solitary pancreatic transplantation in non-uraemic diabetic patients have been less favourable due to a high rejection rate in combination with difficulties in rejection diagnosis and treatment. However, the introduction of new immunosuppressive drugs over the last few years has drastically improved the survival of solitary pancreatic grafts and allows for a rising enthusiasm. The majority of the 122 transplantations performed in Oslo so far were simultaneous kidney and pancreas transplantations. Duct occluded segmental grafts were used until 1988 when the pancreatico-duodenal technique with bladder drainage was introduced. In March 1998 we changed to enteric drainage of the exocrine pancreas due to a high percentage of lower urinary tract problems and bicarbonate loss associated with the bladder drainage technique. The positive impact of a functioning pancreas transplant on the recipient's quality of life is well recognised, whereas long-term beneficial effects on the secondary complications of diabetes are not well documented. A short overview of various aspects of pancreas transplantation is given, including experience with the 122 transplantations performed at the National Hospital, Oslo, Norway.

A strong impact of matching for a limited number of HLA-DR antigens on graft survival and rejection episodes: a single-center study of first cadaveric kidneys to nonsensitized recipients

BACKGROUND

A single-center study of 655 nonsensitized recipients of primary cadaveric kidney grafts is presented.

RESULTS

Graft survival in serologically HLA-DR 1-10 antigen-matched grafts to nonsensitized recipients at 1 year was 90%, compared with 82% (P=0.004) and 73% (P=0.001) in one and two DR antigen-mismatched grafts. The corresponding figures at 5 years were 76%, 62%, and 56%, respectively. Matching for the DR antigens 11-14, or for some DR alleles only detectable by genomic typing, further improved graft survival, but the differences did not reach statistical significance. Matching also for the serologically defined HLA-A and -B antigens did not significantly further improve overall graft survival, but some effects for grafts surviving at least 1 year were observed. Among recipients of grafts mismatched for zero, one, or two HLA-DR antigens, acute rejection episodes were experienced in 48%, 64% (P<0.001), and 82% (P<0.001), respectively, within the first 3 months. HLA-A and -B mismatches showed no significant correlation to acute rejection episodes.

CONCLUSION

Matching for the DR antigens 1-10 significantly secures and prolongs the survival of first cadaveric renal grafts. Our results also show that DR 1-10 antigen-matched combinations can often be obtained even in rather small recipient pools, when actively sought for.

Unrelated living donors in 141 kidney transplantations: a one-center study

BACKGROUND

Kidney transplantation is the optimal treatment for the majority of patients with end-stage renal disease. However, the shortage of kidneys for transplantation is a global problem, and any attempt to improve the donor situation would be of benefit to the growing number of patients on transplant waiting lists.

PATIENTS AND METHODS

Since 1984, we have transplanted 141 kidneys from genetically unrelated living donors. Donors were most often spouses and were accepted regardless of HLA match grade. Preemptive transplantation was performed in 39% of the patients. Standard triple-drug immunosuppression with prednisolone, cyclosporine, and azathioprine was used. The patients were followed from 6 months to 13 years.

RESULTS

The incidence of acute rejection during the first 3 months after transplantation was higher in recipients of grafts from unrelated donors than in recipients of grafts from related living donors or cadaveric donors. However, unrelated living donor grafts survived significantly better than did cadaveric grafts (P < 0.02) and had a survival rate similar to that of living-related donor grafts mismatched for one or both HLA haplotypes. The perioperative complication rate for the donor was low.

CONCLUSION

We consider unrelated living donors an excellent source for alleviating the shortage of donor kidneys.

Routine perioperative antibiotic prophylaxis in renal transplantation

BACKGROUND

Perioperative antibiotic prophylaxis may prevent infection following renal transplantation but it also contributes to development of resistant microorganisms. With refined surgical techniques, improved graft preservation, and immunosuppressive monitoring during recent decades one can question the present use of perioperative antibiotic prophylaxis. We retrospectively evaluated the incidence of infection in our renal transplant centre where antibiotic prophylaxis is not routinely used in renal recipients. Concurrently we performed a survey of perioperative antibiotic use to establish the current world-wide practice.

METHODS

Infection episodes were evaluated from records of 448 adult renal transplant recipients (January 1994 to August 1996) at our centre. A questionnaire was mailed to 103 centres addressing the number of kidney transplantations in 1995, donor source (living vs cadaveric) and details on use of perioperative antibiotic prophylaxis.

RESULTS

Single-centre study. Renal transplantation was performed without antibiotic prophylaxis in 377 patients (84%). Thirteen patients (3.4%) had early postoperative infections, nine with urinary-tract infection tended to have urinary catheter for a longer period than those without infection (5.0 +/- 2.7 vs 3.4 +/- 1.4 days, P = 0.27) and cadaveric kidney recipients to have higher incidence of infections (4.5 vs 1.5% P = 0.14). All infection episodes were successfully treated. The infection incidence in 71 (16%) 'high-risk' patients selected for antibiotic treatment was 4.2%. World-wide survey. Data were obtained from 101 centres in five continents representing 10532 renal transplants. Ninety centres (89%) used perioperative antibiotic prophylaxis.

CONCLUSION

The infection incidence in patients who did not receive perioperative antibiotic prophylaxis was the same as in a small group of selected patients who received prophylaxis. The incidence was lower than usually reported in the literature. In contrast perioperative antibiotic prophylaxis is given to all patients in almost 90% of transplant centres worldwide. A reduction of prophylactic antibiotic use is encouraged.

[Cadaver organ donation in Norway 1993-96]

The annual number of cadaveric organ donors increased from 13.1 per million inhabitants in the period 1989-92 to 15.8 in the period 1993-96. Multiple organ harvesting was performed in 68% of the donors. There are significant differences in donation rate between health regions. An increase to 20 organ donors per year per million inhabitants is required to meet the anticipated need for organs. Strategies to increase organ donation are discussed.

Organ exchange in the Nordic countries

Scandiatransplant is an organ exchange organisation founded in 1969. It serves a population of 23 million inhabitants in the five Nordic countries; Iceland, Norway, Sweden, Finland and Denmark. Scandiatransplant maintains a common central waiting list for all Nordic patients waiting for necro-organ transplantation. The waiting lists are maintained on a central computer by each of the eleven transplant centres in the organisation. The number of necro-organ donors in Scandiatransplant is about 340-375 yearly, corresponding to 15-16 donors per million population (PMP) per year. Since the foundation, a total of 14,500 necro-kidney transplants have been performed, and the number of transplants with extrarenal organs is steadily increasing. Presently, about 7-8 liver transplants PMP are being performed, and the heart transplant activity amounts to about 5 PMP. The supreme authority of Scandiatransplant is the Council of Representatives, in which each transplant centre is represented by one or more professionals who are clinically active in organ transplantation. The responsibility for day-to-day operations lies with the Board which has one member appointed by each of the five Nordic countries and a chairman elected by the Council. The activities of Scandiatransplant are financed exclusively by the participating centres.

Scandiatransplant: organ transplantation in the Nordic countries 1996

The Nordic collaboration in organ transplantation was initiated nearly 30 years ago in the frame of Scandiatransplant. With a recent formalization of its structure, Scandiatransplant has become a modern organ exchange organization. The increasing activities of Scandiatransplant clearly reflect the continuously growing need for a close and firm Nordic collaboration in the transplantation field, for the benefit of the numerous patients waiting for an organ transplant.

Bilateral nephrectomy simultaneously with renal allografting does not alleviate hypertension 3 months following living-donor transplantation

Severe hypertension prior to renal transplantation has traditionally been an indication for bilateral nephrectomy. The reasons for hypertension after successful renal transplantation are however many, and the impact of simultaneous bilateral nephrectomy (BN) in this setting has not been well documented. We retrospectively evaluated 158 living-donor renal graft recipients. BN had been performed in 76 patients at the time of the transplantation and 82 were not nephrectomized (controls). All received a triple immunosuppressive drug regimen. Before transplantation, patients in the BN group used 1.8 +/- 0.9 (mean +/- SD) antihypertensive drugs/day, significantly more than in the control group (1.3 +/- 0.8; P < 0.05). Three months after renal transplantation no difference was found (0.9 +/- 1.0 drugs/day in the BN group vs 1.0 +/- 0.8 drugs/day in the control group). No difference was found with respect to serum creatinine, whole blood cyclosporin A (CsA) concentration or blood pressure between the groups. The number of blood transfusions during the first week after transplantation was significantly increased in the BN group (66 SAG units vs 4 SAG units). The median hospitalization length was also longer in the BN group (21 days vs 16 days). In order to circumscribe the pre-transplant difference in use of antihypertensive medication we studied a subgroup of 62 hypertensive recipients (BN/control = 31/31) matched for number of antihypertensive drugs at the time of transplantation (2.3 +/- 0.5 drugs/day in the BN group, 2.1 +/- 0.3 drugs/day in the control group). Three months after transplantation the use of antihypertensive drugs remained the same in the two groups (1.3 +/- 1.0 drugs/day in the BN group vs 1.3 +/- 0.9 drugs/day in the control group). At 3 months no difference was found between the two hypertensive subgroups regarding serum creatinine, whole blood CsA and haemoglobin concentration or systolic blood pressure. However, the BN patients were younger than the control group (38 +/- 10 years vs 49 +/- 11 years, P < 0.05) and this may explain the marginally lower diastolic blood pressure observed in the BN group (82 +/- 10 mmHg vs 87 +/- 7 mmHg, P < 0.05). It is concluded that, in recipients of living-donor grafts, bilateral nephrectomy performed at the time of transplantation did not influence the number of antihypertensive drugs used 3 months after a successful transplantation. Bilateral nephrectomy did however increase the need of blood transfusions during the first week after transplantation and also the hospitalization length.

Glomerular ultrastructure in kidneys transplanted simultaneously with a segmental pancreas to patients with type 1 diabetes

BACKGROUND

Pancreas transplantation has been reported to prevent development and progression of diabetic glomerulopathy.

STUDY DESIGN

Kidneys transplanted to type 1 diabetic patients were investigated for signs of diabetic glomerulopathy. Biopsies were obtained from 11 patients 2-4 years after simultaneous pancreas and kidney transplantation and from six patients 2-6 years after kidney transplantation alone. During follow-up, glycaemic control was monitored as glycated haemoglobin and, in the pancreas transplant patients, as i.v. glucose tolerance.

RESULTS

Measures of glycaemic control were consistently normal in only two pancreas transplant patients. Four had mean k values <1.0. In kidney biopsies from the pancreas transplant patients, thickness of the glomerular basement membrane was 395 (0.13) nm (mean, coefficient of variation), which is higher than normal (324 (0.13) nm, P=0.01) and not different from diabetic patients with kidney transplants alone, 418 (0.15) nm. The mean calculated annual increase in thickness did not differ between patients with and without a pancreas transplant, 26 (0.77) versus 29 (0.54) nm/year. Estimates of the mesangium and mesangial matrix were in the normal range in both groups while the interstitial volume fraction was increased and to a similar extent.

CONCLUSION

The increase in thickness of the glomerular basement membrane in kidneys transplanted simultaneously with a segmental pancreas is probably an expression of diabetic glomerulopathy caused by the modest impairment in glucose metabolism present in most patients.

[Free vascular grafts in reconstructions in the head and neck region]

Since 1989, 40 free-tissue grafts were used in 39 patients to repair defects following major head and neck ablative surgery (n = 32) and for reconstruction of the mandible because of osteoradionecrosis or trauma (n = 7). The radial forearm flap was used in 17 patients (five including a segment of radius), the lateral arm flap in seven, fibula in five and a segment of ileum for restoration of the hypopharynx in 11 cases. Three radial forearm flaps and the bone in one lateral arm flap failed. Better functional and cosmetic results seem to be obtained with free flaps than with other reconstructive techniques.

[Severe mucormycosis after organ transplantation. Report of a case]

Opportunistic infections remain one of the penalties of the immunosuppression required for successful outcome of organ transplantation. We report the case of a 51 year old woman who, after having received combined kidney and pancreas transplants, developed invasive mucormycosis in the gastrointestinal tract. The hallmarks of successful management of this rare but potentially fatal fungal infection are radical surgical debridement, aggressive antimycotic therapy and control of any underlying diseases. Diagnostic and therapeutic approaches are discussed.

[Pancreas transplantation. A 10-year material]

A programme for pancreas transplantation was initiated in Oslo in 1983. Of a total of 100 transplants so far, 14 were performed as pancreas transplantation alone (PTA) in non-uremic diabetics (n = 9), or as pancreas after kidney (PAK), i.e. in diabetic patients with a functioning renal transplant (n = 5). Duct occluded segmental grafts were used until 1988, when the pancreaticoduodenal technique with bladder drainage was introduced. Since 1991, owing to a low graft survival rate in PAK and PTA cases, all pancreas transplantations have been performed simultaneously with a renal transplant, giving a one-year survival of 82%, 83% and 93% for kidney, pancreas and patient respectively. The authors give a brief overview of the experience gained during ten years, with a pancreas transplant rate of ten/year.

Aortoiliac reconstruction in preparation for renal transplantation

Aortoiliac angiography has always been an integral part of the pretransplantation work-up of renal transplant candidates in Norway. The present study was undertaken to investigate the value of this routine. Based on the angiograms of approximately 1400 patients evaluated for renal transplantation during the 7-year period 1984-1991, 26 were found to have aortic and/or iliac atherosclerosis requiring pretransplant vascular reconstruction. Fifteen of the 26 patients had aneurysm of the abdominal aorta and 11 had extensive aortoiliac occlusive disease. A prosthetic graft was inserted in 25 patients and endarterectomy of the aortic bifurcation was performed in one. The cause of death was coronary heart disease in four of six patients who died before, and in one patient who died after, transplantation. Sixteen patients received a renal transplant while four patients are still on the waiting list. Fifteen of the recipients are alive, 14 with functioning renal transplants. The low yield of patients below 40 years of age requiring vascular reconstruction calls into question the routine use of angiographic investigation of renal transplant candidates below this age. However, we recommend this routine for the higher age groups because it often provides the surgeon performing the transplantation with valuable information. Aortoiliac reconstruction as preparation for renal transplantation is advocated when atherosclerosis of a degree that may preclude transplantation is found. Because of the high risk of myocardial infarction in these patients, one must be especially aware of coronary atherosclerosis when evaluating patients for this procedure.

Fibro-muscular renal artery disease treated by extracorporeal vascular reconstruction and renal autotransplantation: short- and long-term results

Over a 16-year period (1973-1989), 63 renal autotransplants were performed in 59 patients for fibro-muscular dysplasia (FMD) with renal artery stenoses (42 kidneys) or aneurysms (21 kidneys). About two-thirds of the autotransplants were performed before percutaneous transluminal angioplasty (PTA) was established for clinical use. However, vascular disease at a site or type not suitable for PTA was present in 57 (90%) of the kidneys. Hypertension was the leading symptom in 56 patients, including four in whom renal autotransplantation was performed as an emergency for acute renal artery occlusion or malignant hypertension. Blood pressure returned to normal or improved in 51 (91%) and remained unchanged in five patients (9%) following autotransplantation. Three patients with renal artery aneurysm in whom haematuria and loin pain were the indications for treatment, became asymptomatic following surgical intervention. Bilateral renal autotransplantation was performed synchronously in one and sequentially in three patients. There were no operative deaths, but two kidneys were lost postoperatively in two 2-year-old children owing to renal vascular thrombosis. In the follow-up period (mean 4.3 years), one additional kidney was lost at 3 months owing to progressive FMD. Blood pressure and renal function remained stable in all other patients. Based on the excellent results achieved in this series, it is concluded that extracorporeal vascular repair and renal autotransplantation is a safe procedure for the patient as well as the kidney affected by FMD. The procedure is advocated as an alternative to in situ reconstruction in patients with renal artery disease not accessible to PTA, such as aneurysms and complex branch renal artery stenoses.

Fifteen years' experience with renal transplantation in systemic amyloidosis

At our center 62 renal transplantations (31 living donor and 31 cadaveric donor grafts) have been performed in 58 patients with amyloid renal disease since 1974. The amyloidosis was secondary to rheumatic disease in 74% of the patients. Predialytic transplantation was performed in 28% of the patients. Mean follow-up time was 5.1 years (0.3-14.5 years). One-year actuarial patient survival was 79%, decreasing to 65% after 5 years. First graft survival was 74% at 1 year and 62% at 5 years. Patient death with a functioning graft caused 16 out of 25 graft losses. Infections caused 11 out of 18 deaths (61%), more than half of them within 3 months. Renal transplant amyloid was diagnosed in about 10% of the cases (6/62); however, only about 3% of the grafts (2/62) were lost. These long-term results encourage transplantation in amyloid renal end-stage disease.

CT and angiography in adrenocortical carcinoma

CT and angiography were performed in 15 patients with adrenocortical carcinoma. The tumors had a mean diameter of 11 cm (range 4-20 cm). At CT, the 8 largest tumors were ill-defined, and in these, the organ of tumor origin could not be established. Angiographically the correct organ of tumor origin was established in all but one patient. It is concluded that CT is excellent in showing the extent of an adrenal tumor, but is often unable to predict the organ of origin in large tumors. Angiography is still of great value in the preoperative work-up in patients with large adrenocortical carcinomas for correct identification of tumor origin and for vascular mapping.

Long-term metabolic control in recipients of combined pancreas and kidney transplants

Metabolic glucose control was followed in 36 patients at 12-month intervals for up to 5 years after a successful combined kidney and segmental duct-occluded pancreas transplantation. All recipients had normal blood glucose levels at each examination. HbA1 values, intravenous glucose tolerance test, C-peptide levels and C-peptide responses to glucagon stimulation were also, on average, within the normal range. Several individual patients had, however, abnormal values for these parameters. At most 46% had abnormal values for HbA1 and intravenous glucose tolerance test, up to 13% showed low C-peptide values and up to 46% of the stimulated C-peptide responses were inadequate at the different intervals. These parameters did not deteriorate with time. This was true both for the whole group of patients as well as for the 6 patients with a 5-year observation time evaluated separately. Despite these abnormalities in glucose metabolism, all patients remained normoglycaemic without need for exogenous insulin up to 5 years after transplantation. The long-term ability of duct-occluded segmental pancreatic grafts to preserve euglycaemia therefore seems to remain intact at least for 5 years.

Indications and results of pancreatic transplantation: the Oslo experience 1983-1990

The Norwegian pancreas transplantation programme was initiated in June 1983. By November 1990, a total of 77 pancreatic transplantations had been performed, 63 simultaneously with a renal transplant. Five patients received pancreatic grafts after previous renal grafting while nine non-uraemic diabetic patients received pancreatic grafts only. In April 1988, the surgical technique was changed from duct-occluded segmental pancreas to whole pancreas grafting with duodenocystostomy. In recipients of combined grafts from the first group (segmental pancreatic grafts), the 1- and 5-year survival rates were 96% and 90% for the patients, 84% and 69% for renal grafts and 66% and 45% for pancreatic grafts. In the second group (whole pancreatic grafts with duodenocystostomy), the 6-month and 2-year survival rates were 87% at both intervals for the patients, 87% and 75% for both grafts. However, even though the bladder drainage technique allows isolated pancreas graft rejection to be diagnosed, the results of isolated pancreas grafting were not improved by this technique, and most of these grafts were lost in therapy-resistant graft rejection.

Rehabilitation and quality of life in diabetic patients after successful pancreas-kidney transplantation

Twenty-seven Type I diabetic patients in end-stage renal failure were followed after combined pancreas-kidney transplantation. All patients received duct-occluded segmental pancreas grafts. Clinical progression of extrarenal diabetic complications was studied in 11 patients with long-term functioning pancreatic and renal transplants (Group 1), and in 16 patients who had lost pancreatic graft function, but retained renal graft function (Group 2). Pretransplant, extrarenal diabetic complications were equally distributed in the two groups. In the follow-up period, however, the progress of these complications was less severe in patients with functioning pancreatic transplants. No differences were found between the groups concerning rehabilitation, working capacity, need of help or hospital admittance. It is suggested that pancreas transplantation performed in an earlier stage of diabetes before serious complications have developed, would probably improve rehabilitation and quality of life in these patients.