Selective Use of Expanded Criteria Donors for Renal Transplantation With Good Results

Increasing demand for renal transplants has stimulated expanded criteria for the use of deceased donors. Recently an official category of "Expanded Criteria Donors" (ECD) was designated by UNOS. This category included any deceased donor (1) greater than age 60 years or (2) age 50 to 59 years with any two of: (a) creatinine greater than 1.5 mg/dL (b) cerebrovascular accident cause of death, or (c) hypertension history. It has been anticipated that at 3 years, 70% of ECD kidneys with serum creatinine greater than 1.5 would be lost. We reviewed our experience with the use of this type of kidney prior to the era of officially designated ECD. Survival rates and serum creatinines were compared to standard criteria donor recipients for the same time period whose donor was greater than 50 years of age and correlated with biopsies. From 1996 to 2003, 341 deceased donor kidneys were transplanted at our center. Of these, 37 were ECD kidneys and 46 were standard criteria donors kidneys. Four pretransplant biopsies had greater than 20% sclerosed glomeruli. Four donors had 0% to 25% arteriosclerosis pretransplant; on postperfusion biopsy, eight had 0% to 25% arteriosclerosis, while three had 25% to 50%. The mean donor age was 61 years; mean recipient age was 54 years; recipient sex was 57% male, and 54% of the recipients were African-American. At 1, 2, and 3 years posttransplant, there was no significant difference between the two groups in serum creatinine, graft survival, or patient survival. Despite using ECD donors, good long-term function can be obtained, particularly if selectivity is exercised.

No-Load Sirolimus With Tacrolimus and Steroids Is Safe and Effective in Renal Transplantation

AIM

Basiliximab (BX) induction, tacrolimus (TAC), and steroids have sharply reduced acute cellular rejection at our institution. However, late graft loss has continued, for which sirolimus (SL) was introduced into the protocol.

METHODS

From July 1, 2001 to December 31, 2003, 152 live donor (LD) renal transplant recipients received TAC (level 15 to 20 ng/mL) and steroids, with BX induction. One hundred twenty-two patients (Group 1) received SL (3 mg/d African-americans; 2 mg/d for others) starting on days 2 and 3. The SL level was adjusted to 8 to 10 ng/d, usually by weeks 3 to 4 posttransplant. The TAC doses were then progressively reduced. Records were reviewed for demographics, immunosuppressive drug levels, serum cholesterol and blood pressure, and complications. Graft and patient survival rates were calculated. Comparison was made to 53 LD recipients transplanted from July 1, 1998, to June 30, 2001 (Group 2) receiving BX, steroids and TAC, without SL. Recipients of deceased donor kidneys were excluded because of variability in kidney quality, ischemic time, and patient management.

RESULTS

Demographics were similar between groups: African Americans, 25% to 35%; mean age 36 years; mean HLA mismatch 3.7. Wound problems and infection were minimal in both groups. Mean serum creatinine and cholesterol and systolic and diastolic blood pressure measured periodically up to 1 year were similar, as was the incidence of rejection. In 25% of patients, SL was discontinued.

CONCLUSIONS

Gradual introduction of SL appears to be associated with minimal wound problems. With more aggressive reduction in TAC, better renal function, and better long-term graft survival may be attainable. We currently lower TAC levels to 5 ng/mL by 3 months.

Primary intestinal posttransplant T-cell lymphoma

There have been only five reported cases of primary posttransplant T-cell lymphoma. We report the first case associated with the use of sirolimus (Rapamycin, Wyeth-Ayerst, Philadelphia, PA). The patient, receiving prednisone, cyclosporine, and sirolimus treatment, developed ascites, diarrhea, and weight loss 7 months after his second renal transplant. Tissue obtained at laparotomy established the diagnosis of primary T-cell lymphoma. Latent membrane protein-1 for Epstein-Barr virus was negative, but in-site hybridization test for Epstein-Barr-encoded RNA was positive. Despite aggressive chemotherapy, the patient died 8 months posttransplant. This is the sixth reported case of primary intestinal posttransplant T-cell lymphoma, but it is the first case associated with the use of sirolimus. The incidence of posttransplant lymphoproliferative disease in patients receiving sirolimus should be studied.

Fifteen-year experience with pediatric renal transplantation at the Montefiore Medical Center

At Montefiore Medical Center, 140 pediatric recipients have received 155 renal allografts over a 16-year period with an overall 6% mortality. Graft survival was not significantly different based upon race or sex of recipient. Graft survival was significantly better for first time transplants and the youngest recipients. Graft survival was significantly improved using Tacrolimus immunosuppression.

Basiliximab induction improves the outcome of renal transplants in children and adolescents

Thirty-two children and adolescents received their renal transplant at the Montefiore Medical Center, in New York, between October 1996 and May 2000. Twenty-four patients received basiliximab, in addition to tacrolimus and steroids (basiliximab group). The remaining eight patients received only tacrolimus and steroids (non-basiliximab group). The 1-year patient survival rate was 100% in both groups. The 1-year graft survival rate was 87.5% for the basiliximab group and 75% for the non-basiliximab group (P=0.45). The rates of acute rejection in the basiliximab and non-basiliximab groups were 26% and 43%, respectively (P=0.36). However, in recipients with <or=3 HLA mismatches, the rate of acute rejection was zero in the basiliximab group, and 40% in the non-basiliximab group (P=0.04). The beneficial effect occurred despite the fact that tacrolimus was maintained at below the target levels. There were no adverse events directly attributable to the administration of basiliximab. There were no cases of opportunistic infections or post-transplant lymphoproliferative disease. In summary, addition of basiliximab to tacrolimus and prednisone significantly decreased the rate of acute rejection in well-matched patients. Moreover, this effect was manifest at lower, and therefore less toxic, tacrolimus levels.

Reversible sensorineural hearing loss following administration of muromonab-CD3 (OKT3) for cadaveric renal transplant immunosuppression

This prospective study is a follow-up to a case report noting reversible sensorineural hearing loss after administration of OKT3 for immunosuppression in a steroid-resistant renal cadaveric transplant patient who was rejecting his transplant. The objective is to determine the interval estimate for incidence of sensorineural hearing loss following treatment with OKT3. Seven patients were admitted to the Renal Transplant Service at Montefiore Medical Center from July 1996 to July 1997 with steroid-resistant rejection of renal cadaveric transplants and received OKT3 as an immunosuppressant. All 7 patients received 3 audiograms: the first, prior to the administration of the first dose of OKT3, the second, 48 to 72 hours after administration of OKT3, and the third, approximately 2 weeks after administration of OKT3. Five of the 7 patients (71%) demonstrated a sensorineural hearing loss of 15 dB or greater at frequencies of 8 to 12 kHz. Four of the 5 patients with audiographic changes had near-complete to complete recovery of their high-frequency thresholds after discontinuation of the drug regimen. In conclusion, OKT3 can cause sensorineural hearing loss. This side effect is mainly reversible after 2 weeks following discontinuation of the drug. Patients receiving OKT3 should be forewarned of this possible side effect prior to the administration of OKT3.

Effects of erythropoietin, angiotensin II, and angiotensin-converting enzyme inhibitor on erythroid precursors in patients with posttransplantation erythrocytosis

BACKGROUND

Angiotensin-converting enzyme inhibitors (ACEI) have become the treatment of choice for posttransplantation erythrocytosis (PTE). Yet the pathogenesis of PTE and the mechanisms of action of ACEI remain unclear. Therefore, we studied the dose response to erythropoietin (Ep), angiotensin II (AII), and the ACEI enalaprilat on the in vitro proliferation of erythroid progenitors in patients with PTE and in controls. We also evaluated ACE polymorphism in the two groups.

METHODS

Twelve patients with PTE and 12 renal transplant patients without PTE were studied. Erythroid burst-forming units (BFU-E) were isolated from peripheral blood using standard methods. Ep sensitivity was determined for four patients with PTE and three control patients, using 0-3 U/ml Ep. AII dose response was studied in four patients with PTE and five control patients, using AII concentrations of 0-1000 nM. The effect of enalaprilat was studied in eight patients with PTE and eight control patients, using drug concentrations of 0-10 ng/ml. ACE gene insertion/deletion polymorphism was determined by polymerase chain reaction.

RESULTS

PTE patients showed a significant shift of the Ep response curve to the left compared with controls, with 50% maximal growth occurring at a lower Ep concentration (0.3 U/ml vs. 0.95 U/ml, P<0.025.) However, there was no difference in the number of BFU-E colonies between PTE patients and controls. AII added to the growth medium produced only minor stimulation in both groups. PTE patients showed significant inhibition of BFU-E growth with 10 ng/ml enalaprilat, but controls showed no inhibition of BFU-E growth with ACEI. There was no difference in ACE polymorphism between PTE and controls.

CONCLUSIONS

Our data suggest that PTE is associated with increased erythroid progenitor sensitivity to Ep. The effect of ACEI to decrease hematocrit in patients with PTE may be due to inhibition of red cell precursor growth.

Comparison of clinical features and liver histology in hepatitis C-positive dialysis patients and renal transplant recipients

OBJECTIVE

Liver biopsies in hepatitis C virus (HCV)-positive end stage renal disease (ESRD) patients before or after renal transplantation were compared to study the effect of transplant-related immunosuppression.

METHODS

In this prospective study all patients on the active transplant list and all patients with functioning renal transplants at our hospital were tested for HCV antibody (ELISA-2) over a 30-month period. HCV infection was confirmed by polymerase chain reaction in most patients. All HCV-positive patients were asked to undergo liver biopsy without regard to serum transaminase levels. Patients were interviewed, examined, and had detailed chart review. By protocol, liver histology was evaluated according to stage and inflammatory activity in a blinded fashion.

RESULTS

There were 129 HCV-antibody-positive patients, of 795 tested. Sixty-seven agreed to liver biopsy. Of these, 22 patients had never been transplanted and 45 had received transplants. Mean transplant duration before biopsy was 41.2 months (range, 1-204 months). Transplant patients had significantly longer duration of ESRD and estimated duration of HCV infection than patients not transplanted. Dialysis patients had significantly more portal inflammatory activity and lymphoid follicles on biopsy whereas transplant patients had more piecemeal necrosis and steatosis. However, the total histological activity score and stage were similar between groups. Multivariate analysis confirmed the association between transplant and steatosis. But independent variables including transplant duration, HCV infection duration, and ESRD duration were not correlated with histological findings.

CONCLUSION

Renal transplantation may not be associated with an increased risk of progressive liver disease in HCV-positive patients, compared with ESRD patients receiving chronic dialysis. Long-term studies with serial liver biopsies are needed to resolve this issue.

Renal transplantation in a heterogeneous population: the thirty-year Montefiore Medical Center experience

Based on more than 30 years of renal transplantation experience at Montefiore Medical Center we conclude: 1. Improved patient and graft survival can be achieved in the cadaveric transplant recipient despite increasing co-morbidities. 2. Patients at the extremes of age (< 10 or > 60) can undergo renal transplantation safely, with patient and graft survival rates approaching those of the general recipient population. 3. Results of transplantation in African-Americans are as good as non African-Americans at 3 years. Beyond that point the graft survival curves diverge. Well matched (0-1 HLA mismatches) kidneys in the African-American patient do as well if not better than other ethnic groups. However, African-Americans do not receive as many well matched kidneys as others.

Urine cytology and the diagnosis of renal allograft rejection. I. Studies using conventional staining

OBJECTIVE

To determine the reproducibility and validity of urine cytology for the diagnosis of acute renal allograft rejection (AR).

STUDY DESIGN

We conducted a blind, prospective study of 10 renal allograft recipients. Freshly voided aliquots of urine were obtained on each hospital day and at each outpatient visit for a mean of 52.8 +/- 26.2 (SD) days following transplantation. The samples were prepared by cytocentrifugation and then stained by a modified Papanicolaou method. To determine interobserver reproducibility, the differential cell counts of two blinded cytopathologists were compared. A cytodiagnosis of AR was made when the urine sample contained < 55% neutrophils and > 20% lymphocytes. To determine the validity of the cytology, the result was compared to the histologic and clinical diagnoses. Biopsies were obtained one hour following vascular anastomosis and at the time of graft dysfunction and were scored by two blinded pathologists according to the Banff classification. The clinical diagnosis was determined by a retrospective review conducted by four blinded clinicians.

RESULTS

The interoperator reading of urine cytology was more reproducible than histology, with kappa values of 0.40 +/- 0.15 (SE) and 0.21 +/- 0.10 (SE), respectively. Urine cytology was accurate for the diagnosis of AR, with a sensitivity of 80% and a specificity of 96% as compared to the clinical and histologic findings.

CONCLUSION

Our observations support the claim that urine cytology is useful for diagnosing AR.

Urine cytology and the diagnosis of renal allograft rejection. II. Studies using immunostaining

BACKGROUND

Urine immunocytology may provide a noninvasive method of investigating the antigens expressed by renal tubular cells. In previous investigations of patients with acute renal allograft rejection (AR), we showed that the adhesion molecule ICAM-1 is expressed by voided tubular cells. The up-regulation of ICAM-1, in turn, may be due to high circulating levels of interferon-gamma and/or TNF-alpha. We investigated the regulation of receptors for these cytokines and found a correlation between their expression and clinical events.

STUDY DESIGN

For 10 patients who received transplants consecutively, freshly voided aliquots of urine were obtained on each hospital day and on each outpatient visit for a mean of 52.8 +/- 26.2 (SD) days. After cytocentrifugation, the samples were prepared by the avidin-biotin-immunoperoxidase technique in order to detect the presence or absence of ICAM-1, interferon-gamma receptor and TNF-alpha receptor (p 80) on the tubular cells.

RESULTS

In nonrejecting patients, the tubular cells expressed the interferon-gamma receptor but not ICAM-1 or the TNF-alpha receptor. In patients with AR, the pattern was different. The tubular cells expressed ICAM-1 and the TNF-alpha receptor but not the interferon-gamma receptor.

CONCLUSION

Urine immunocytochemistry may be useful to demonstrate the expression of cytokine receptors by renal epithelia.

Prevalence of asymptomatic cholelithiasis and risk of acute cholecystitis after kidney transplantation

Prophylactic cholecystectomy for asymptomatic cholelithiasis is sometimes required before transplantation. However, there is little indication in the literature that transplant recipients are at any greater risk than individuals in the general population. Between January 1990 and December 1993, 211 renal transplant recipients underwent duplex sonography. All were asymptomatic. Twenty-one had positive findings: gallstones were found in 15 patients (7.11%) and sludge was found in 6 (2.84%). Of gallstone patients, seven (3%) were men and eight (4%) were women. One gallstone patient also had diabetes mellitus. The mean age by gender of the patients with calculi was 54 years for men and 38 years for women. Thirteen of the 15 patients with calculi (87%) have remained asymptomatic. Two patients (one diabetic) developed acute cholecystitis and underwent uncomplicated laparoscopic cholecystectomy. Patients with sludge were similar in gender and age to patients with gallstones; one patient had diabetes. No sludge patients became symptomatic. The incidence and morbidity of gallstones after kidney transplantation are low. Prophylactic cholecystectomy in asymptomatic patients before transplantation is not justified.

Improved renal allograft survival in children treated with FK 506 (tacrolimus) rescue therapy

FK 506 has been reported to be effective in reversing acute renal allograft rejection that is resistant to steroids and to OKT3. The contribution of FK 506 "rescue" therapy to long-term graft survival has not been determined. We report 23 children transplanted between January 1993 and December 1994, 10 of whom received FK 506 "rescue" therapy. Acute rejection was reversed in 8 of 10, with 7 of the remaining grafts still functioning after a mean follow-up of 10.9 +/- 7.8 (SD) months (range 1-26 months). The actuarial 1-year graft survival rate was 86% compared with 66% for historical controls (P < 0.05). We conclude that FK 506 may provide long-term benefits to children facing allograft loss due to acute rejection.

The effect of donor gender on renal allograft survival

Donor gender plays a role in the outcome of renal transplantation, but the mechanisms responsible for this effect are unclear. In this study, actuarial graft survival in 1049 recipients transplanted at Montefiore Medical Center between 1979 and 1994 was examined. It was found that donor gender had no influence on graft survival in recipients treated with precyclosporine immunosuppressive agents. In contrast, graft survival time was greater in cyclosporine-treated recipients of male donor kidneys compared with female kidneys (p < 0.05). This survival time difference was evident in the early post-transplant period and was entirely accounted for by the survival advantage of kidneys from white male donors. There was no gender-related difference in graft survival time among recipients of African-American donor kidneys. Recent attention has focused on the hypothesis that a mismatch between female donor kidney nephron supply and male recipient functional demand results in hyperfiltration-mediated glomerular injury and that this is responsible for reduced survival time of female allografts. Any hypothesis purporting to explain gender-related differences in graft survival time must take into account this study's observations that the donor-gender effect was observed only in cyclosporine-treated recipients, was not seen in African-American donors, appeared soon after renal transplantation, and did not increase progressively with time. These observations are most consistent with the hypothesis that gender-related differences in graft survival time may reflect differences in susceptibility to cyclosporine nephrotoxicity or differences in the therapeutic response to cyclosporine.

Renal allograft rejection in children and young adults: the Banff classification

In the Banff classification, arteritis and tubulitis are regarded as the principal histological lesions indicating acute renal allograft rejection. To test this claim, we examined 51 biopsies obtained from 21 children and young adults with transplant rejection. Two reviewers, blind to the clinical course, graded the biopsies according to the Banff scheme. In patients without significant tubulitis (borderline changes), rejection tended to be reversed easily (88%), often with methylprednisolone pulse (52%). In patients with arteritis or significant tubulitis (Banff I-III), rejection was reversed in only 23% (P < 0.001), in 9% with steroids, and in 14% with OKT3. Salvage of the graft was achieved in 26 of 35 (74%) with a score < 5 but in only 1 of 12 (8%) with a score > or = 5 (P < 0.001). All 6 patients with vasculitis lost their grafts despite methylprednisolone pulse and OKT3. We conclude that the Banff classification predicts accurately the outcome of renal allograft rejection in children and may aid in choosing appropriate therapy.

Analysis of adhesion molecule expression by tubular epithelial cells using urine immunocytology

On their surface, renal tubular cells present intercellular adhesion molecule-1 (ICAM-1) during acute renal allograft rejection. We propose that the extent of ICAM-1 expression by renal tubular cells can be estimated from urine immunocytology. To test this hypothesis, we obtained 52 samples of urine from 31 renal transplant recipients with either acute tubular necrosis, rejection or stable renal function. Cytocentrifuged aliquots of urinary sediment were incubated with monoclonal antibodies to ICAM-1 in an avidin-biotin-peroxidase technique. To corroborate our findings, biopsy specimens were obtained for conventional and immunohistology one hour following vascular anastomosis and during rejection episodes. The proportion of renal tubular cells that expressed ICAM-1 was low in patients with acute tubular necrosis (23.8 +/- 3.6%) and high in patients with rejection (53.1 +/- 4.4% [SEM]) (P < .001). In 11 patients who recovered from rejection, the proportion of ICAM-1-positive renal tubular cells decreased from 55.9 +/- 5.6% to 25.5 +/- 4.3% (P < .05). In two patients who initially had acute tubular necrosis and then rejected their transplants, the expression of ICAM-1 on renal tubular cells tended to increase (from 27.5 +/- 2.5% to 60.0 +/- 20.0%, P = .12). In eight patients with acute tubular necrosis who never rejected their transplants, ICAM-1 expression remained low (23.1 +/- 3.8%). Immunocytology correlated well with immunohistology and the clinical diagnosis. Our findings suggest that urine immunocytology may be useful in monitoring adhesion molecule expression by renal tubular cells.

The fractional excretion of urea: a new diagnostic test for acute renal allograft rejection

Fractional excretion of sodium (FENa) has been used in the diagnosis of acute renal allograft failure on the assumption that poor allograft perfusion should result in a low FENa. However, many patients receive medications which affect the active transport of Na+ and thus FENa. In contrast, the fractional excretion of urea (FEurea) is mostly dependent on passive forces and is therefore less influenced by drug therapy. To test the hypothesis that FEurea might be more useful than FENa in evaluating graft failure, we compared FEurea with FENa during 79 episodes of acute renal allograft dysfunction due to acute rejection (AR), cyclosporine nephrotoxicity (CsA-Nx), viral infection, or bacterial infection in 32 children and young adults with renal transplants. There was no significant difference between groups in FENa. However, FEurea was significantly lower (P < 0.05) in patients with CsA-Nx (32.6 +/- 1.9%) and viral infection (32.9 +/- 3.2%) than those with AR (45.1 +/- 1.7%) or bacterial infection (38.9 +/- 2.5%). FEurea was < 35% in 20 of 28 (71.4%) episodes of CsA-Nx and 8 of 11 (72.2%) of viral infection, but only 5 of 36 (13.9%) of AR (P < 0.05). FEurea was also measured during stable graft function, 7-14 days prior to allograft dysfunction. CsA-Nx was associated with a 30.5 +/- 8.3% decrease in FEurea. FEurea did not change in patients with AR. Based on these findings, we present an algorithm to aid in the differential diagnosis of acute renal allograft failure.

A single center experience with renal transplantation in young children

Results of pediatric renal transplantation have been variable. We evaluated our experience with renal transplantation in children less than 5 years old to determine its safety and efficacy. Of the 428 renal transplants done at our institution from August 1983 to December 1989, 14 were performed in 13 children 13 to 50 months old (mean age 34 months). All of the patients were small for age with height standard deviation scores ranging from -1.7 to -4.5. Patient survival, allograft survival and statural growth were used as determinants of successful outcome. Followup was complete in all patients, including renal function studies and serial height measurements. Growth velocity standard deviation scores were calculated. Patient survival was 100%. Allograft survival was 100% 2 to 7.3 years after transplantation for living related donor recipients whereas 1-year graft survival was poor (40%) for cadaveric graft recipients. Of 10 patients with good graft function at 1 year 9 demonstrated improvement in the height standard deviation score. Seven of 10 patients demonstrated significant catch-up growth (growth velocity standard deviation score greater than 0, p = 0.04). Our study supports the safety and efficacy of renal transplantation in young children. Early transplantation using living-related donor organs is the optimal therapy to prevent growth retardation and allow the young child with end stage renal disease to have a normal life.

Histological evaluation of the inferior epigastric artery in patients with known atherosclerosis

Comparative histological studies have been performed on the various arterial conduits available for myocardial revascularization including the inferior epigastric artery which has recently become the focus of intense investigation. In this study, 10 patients with known risk factors for atherosclerotic disease had their inferior epigastric artery harvested and the entire specimen examined for the microscopical presence of atherosclerosis or its precursors. Histopathological findings that have been shown to be theoretically protective against the progression of atherosclerosis were observed. These include the paucity of fenestrae in the internal elastic lamina, no medical calcification, the absence of foam cells and the absence of intimal smooth muscle cells. No specimen had atherosclerotic disease and only 3 specimens showed changes consistent with minimal intimal hyperplasia. Morphometric analysis of the 3 diseased specimens revealed only minimal luminal narrowing. These findings suggest that the inferior epigastric artery may not be prone to atherosclerosis. Thus, the inferior epigastric artery appears to be a safe myocardial conduit and long-term patency can be anticipated.

Male fertility in cyclosporine-treated renal transplant patients

Fertility and potential fertility were evaluated in 9 young men on cyclosporine A therapy following renal transplantation. Semen analysis was normal in most parameters in 8 patients as was testicular hormonal function. Of 4 men who had attempted to impregnate their wives 3 succeeded. Cyclosporine A does not seem to affect adversely fertility in men.

Percutaneous transluminal dilation in renal transplant arterial stenosis

Twelve hypertensive patients underwent percutaneous transluminal dilation (PTD) for relief of arterial stenosis complicating renal allotransplantation. Two patients underwent repeat PTD for recurrent stenosis and hypertension. Six patients had end to end anastomosis of the donor renal artery to the recipient hypogastric artery; four of six PTDs were successful. Six patients had end to side anastomosis of the donor renal artery to the recipient external iliac artery; seven of eight PTDs, including one of two repeat PTDs, were successful. Prior to PTD, all patients were using several antihypertensive medications. Following successful PTD, the mean blood pressure dropped from 184 +/- 15/118 +/- 9 to 133 +/- 13/89 +/- 11 mm Hg (P < 0.001) and remained at that level for up to 15 months (average followup 9 months) with decreased or no antihypertensive medications. Since surgical correction of arterial stenosis occurring after renal transplantation is difficult and may endanger the graft, PTD should be the first interventional therapy.

Percutaneous transluminal angioplasty in renal transplant arterial stenosis for relief of hypertension

Seven hypertensive patients underwent percutaneous transluminal angioplasty (PTA) for relief of arterial stenosis complicating renal allotransplantation. Four had end-to-end anastomosis of the donor renal artery to the recipient hypogastric artery; all PTA's were successful. Three patients had end-to-side anastomosis of the donor renal artery to the recipient external iliac artery; 2/3 PTA's were successful. Prior to PTA, all patients were using several antihypertension medications. Following successful PTA, the mean blood pressure fell from 190 +/- 10/120 +/- 5 to 132 +/- 16/86 +/- 9 mm Hg (p less than 0.01) and remained at that level for up to six months (average follow-up 2.85 months) with decreased or no antihypertension medications. Since surgical correction of arterial stenosis is difficult and may endanger the transplant kidney, PTA should be attempted first.

Effect of ureteral stent on urinary tract infections in renal transplantation

A retrospective study was carried out to determine the effect of ureteral intubation during renal transplantation. We noted urinary tract infections in 76 per cent of those patients whose ureters were intubated during transplantation, as opposed to 45 per cent in those transplant recipients without ureteral stents. The incidence of recurrent urinary tract infections also increased from 18 to 34 per cent with the use of ureteral catheters. Ten separate episodes of bacteremia, indirectly related to indwelling catheters, are noted.