Steroid and azathioprine versus steroid, cyclosporine, and azathioprine therapies in primary haplo-identical living donor kidney transplantation Twenty-year experience

Achievements in short-term graft survival since the introduction of cyclosporine has not been matched by improvement in long-term graft function, and chronic allograft nephropathy remains the second commonest cause of graft attrition over time. We aimed to evaluate the long-term results of conventional immunosuppression by steroid and azathioprine in comparison with cyclosporine-based triple therapy in living donor kidney transplants. We evaluated the long-term follow-up data of 369 living related kidney transplant recipients that were on prednisolone-azathioprine immunosuppressive therapy [group 1] or triple therapy by prednisolone, cyclosporine, and azathioprine [group 2]. All recipients were followed-up for more than 10 years [mean, 240 +/- 12 months]. Comparative analyses included patient and graft survival rates, condition at last follow-up, graft rejection, and graft function. There were 130 patients in group 1 and 239 in group 2. The overall frequency of acute rejection episodes was not significantly different between the two groups. However, the proportion of patients with chronic allograft nephropathy was significantly higher in group 2 [21% versus 35%, P = .001]. Graft survival rates were 85.3% versus 92.4% at 1 year, 69.9% versus 71.9% at 5 years, and 52.5% versus 50.8% at 10 years in groups 1 and 2, respectively [P = .03]. The two groups were comparable regarding posttransplant malignancies, diabetes mellitus, serious bacterial infections, and hepatic diseases. However, hypertensive patients were significantly more frequent in group 2. Chronic allograft nephropathy was significantly higher in patients receiving cyclosporine, possibly due to the risk of drug-induced nephrotoxicity, glomerular disease recurrence, and hypertension. Nowadays, it is possible to achieve excellent calcineurin inhibitors-free regimen using newer maintenance immunosuppressive agents

Pulmonary effects of thoracic epidural analgesia for cardiac valve replacement surgery

The study was performed on forty patients [ASA physical status II: III] with symptomatic mitral valve disease underwent mitral valve replacement surgery. The patients where criteria were randomly allocated into two equal groups [20 patients each] 1- General anesthesia group [GA] ['control group]. 2- General anesthesia with thoracic epidural analgesia group [TEA group]. Anesthetic technique and management of cardiopulmonary bypass were standardized for all patients. Spirometric data: [FVC, FEV1, FEV1/FVC% and PEFR,], and respiratory rate were measured at the night before surgery, after extubation by 1h, 12h, 24h, 48h, 72h and [6th postoperative day Arterial Blood Gases: PaO2, PaCO2 and pH were measured after induction of GA by 15 min., after extubation by 48h, 72h and 6th postoperative day. Visual analogue scale [VAS] score for assessment of pain was measured after extubation by 1h, 6h, 12h, 18h, 24h, 48h, 72h and 6th postoperative day. Total dose of fentanyl analgesia was calculated in each group. There were some improvement in respiratory function [FVC, FEV 1 and PEFR.] started at the 3rd to the 6th post operative days.There were insignificant changes in FEV1/FVC all over the study period RR decreased significantly in the epidural group than control group in all readings. There was a significant decrease in VAS in TEA group than the control group throughout the study period. PaO 2 was significantly decreased in both groups at all readings. 1. Intensive Care Unit [ICU] stay: There was insignificant difference between the two groups. 2. Time to first awake /hour was significantly decreased in thoracic epidural group than general anesthesia group [1.3 +/- 0.3 vercus 2.5 +/- 0.6]. 3. Time to extubation /hour was significantly decreased in thoracic epidural group than general anesthesia group [3.5 + 0.2 versus 7.3 +/- 0.3]. 4. Total postoperative fentanyl consumption in 1st 24h was a significant decrease in TEA than GA group [p<0. 00] [677.9 +/- 26 in TEA group versus 1203.4 +/- 44 in general anesthesia group] perioperative epidural infusion of 0.125% bupivacaine and fentanyl, started before induction of anesthesia in valve replacement surgery reduces the total requirements of intraoperative narcotics, without cm appreciable delay in extubation. There was slight improvement in pulmonary function, but not to expected values and far less than control reading indicating multifactorial bases of pulmonary dysfunction in cardiac surgery using CBP

Naloxone versus nalbuphine for treatment of intrathecal morphine-induced side effects

This study included 200 adult male and female patients undergoing lower abdominal and anorectal surgeries under spinal anesthesia. All patients received [3 ml bupivacaine 0.5% + 1 mg morphine] intrathecally. Patients were observed for 24 hours postoperatively. One hundred patients requested treatment for moderate to severe symptoms [pruritus, nausea and/or vomiting]. According to the drug used to treat intrathecal morphine-induced side effects, patients were divided randomly into two equal [each of 50] groups: Group I, received nalbuphine in a dose of 2 mg for a maximum of 6 doses [12 mg] and group II, received naloxone in a dose of 0.08 mg for a maximum of 6 doses [0.48 mg]. The remaining 100 patients developed no or mild symptoms requiring no treatment. Those patients constituted group III. Intrathecal morphine in a dose of 1 mg produced moderate to severe side effects [pruritus, nausea and/or vomiting and urinary retention] in a 50% of patients. No incidence of respiratory depression was observed at this dose. Both naloxone and nalbuphine were effective and safe in treating the side effects of intrathecal morphine. However, there was an evidence that nalbuphine may be superior than naloxone as regards the possibility to reverse intrathecal morphine-induced analgesia

Mansoura ATG and steroid resistant rejection

ATG is one of the most effective therapeutic agents in the treatment of acute renal allogrqft rejection, especially when the episode is resistant to steroids. Anti thymocyte globulin [ATG] is a hyperirnmune serum produced in rabbits against purified human thymus cells. Fifteen patches of ATG were prepared locally in our lab. Antibody production was done by injection of purified human thymus cells into about 10-12 rabbits/patch. Adsorption, fractionation and purification of rabbit serum, antibody assays, and quality control tests were done. Our ATG was utilized in 20 patients suffering from sterioid resistant rejection [SRR]. Monitoring of the drug by T cell subsets analysis and Anti ATG antibodies revealed depletion of the total T lymphocytes especially in the early doses beside absence of anti ATG antibodies without any side effects of the preparation on the other haematologic series. Regarding the clinical efficacy of our ATG in reversing SRR, 80% of cases respond completely while partial response was noted in 10% and another 10% showed failure. In conclusion our ATG is as effective as other ATG in saving renal transplantation otherwise the graft will be lost

Haemolytic anaemia after ABO-mismatched living-donor kidney transplantation

ABO.mismatched transplants are used frequently. Acquired haemolytic anaemia have been reported after ABO mismatched transplantation. Among 214 ABO.unmatched living-donor kidney transplants tS, 10 cases with cyclosporine based therapy developed haemolysis All studied patients had pre-transplant non specific blood transfusion and received kidneys from one haplotype HLA mismatched living donors. There were 164 males and 50 females. while the mean age was 30.41 years. CsA was stopped in patients treated with triple Immunosuppression while the patients received Pred-CsA were switched to conventional immunosuppression 6 patients were transfused with washed O cells and no plasma exchange was required. The prognosis was excellent in 9 patient, and one died from severe haemolysis. The haemolytic anaemia was more frequent among blood group A recipients [60% of our cases] and more severe among recipients with blood group B. Univariate analysis demonstrated significant impact for recipient age. donor sex, number of pretransplant blood transfusions. primary immunosuppression, time to onset of diuresis, recipient and donor blood groups. On the other hand, multivariate analysis restricted the significance to blood group of donor and recipient. time to onset of diuresis and primary immunosuppression. ABO unmatched kindray transplantation had no impact on patient survival, mean while the graft survival appeared to be better among unmatched ABO group in comparison to the same blood group recipients