Avascular Necrosis following Renal Transplantation / 대한이식학회지

Between Jan. 1990 and Sep. 1996, 462 renal allografts were carried out at the Ulsan University College of Medicine and Asan Medical Center. This study was undertaken to evaluate a clinicopathologic features, to document a relationship between dosage and duration of the corticosteroids, and to figure out a treatment strategy of avascular necrosis(AVN) of bone in 13 cases of AVN of the femoral head following renal transplantation. A control group of 15 cases were randomly selected among 462 cases of renal allografts to do a comparative study with 13 cases of AVN. The diagnosis of AVN of bone was made on the basis of plain radiographs and MRI or bone scan. 1) The incidence of AVN was 2.8%(13/462). 2) In entire cases, affected site of bone was the femoral head. The main clinical manifestations were hip joint pain, limitation of weight bearing and motion. The mean onset of first bone symptoms of AVN was 5.5 months(1~9 months). 3) Clinical parameters such as age, sex, type and duration of preoperative dialysis, type of donor, rate of body weight change, and duration of follow up had no relation with the prevalence of AVN. 4) The mean total doses of corticosteroids at 1, 3, 6, and 12months post-transplantation were not differ significantly between the two groups. 5) Biochemical parameters, such as BUN/Cr., Ca, /P, /ALP., AST/ALT, cholesterol, glucose, total protein, and albumin had no relation save the preoperative BUN, total protein. 6) The mean duration of diagnosis of this condition were 12.9 months(range, 9~31 months), 6.7 months(range, 1~12 months), 6.9 months(range, 1~14 months) by X-ray, MRI, and bone scan respectively. 4/12(33.3%) cases of AVN was diagnosed by magnetic resonance imaging(MRI) at the time of the first clinical bone symptoms. 7) In AVN group, conservative management were performed in 2 cases, core decompression in 7 cases, and total hip replacement arthroplasty(THRA) were performed in 4 cases of AVN of the femoral head. From this study, we could not illustrate the precipitating factors in transplant recipients using steroid following renal transplantation. We considered that prognosis of AVN depends entirely on early diagnosis using MRI or bone scan, and proper treatment according to the stage of this condition.

Cadaveric Renal Transplantation in High-Risk Donors

We performed a clinical analysis of the 106 cadaveric renal transplants among the 479 renal allograft patients operated between Jun. 1990 and Oct. 1996 to evaluate the graft outcome in patients with high-risk donor factors. Organ procurement were performed in 73 cases(64.4%) among 113 potential donors. In the remaining 40 cases, 22 cases were given up as organ donors due to medical causes, such as severe organ failure (n=9), HBsAg(+) (n=6), cardiac arrest (n=5),and sepsis (n=2). The incidence of acute tubular necrosis was significantly higher for age >50 yr, cold ischemic time(CIT) >24 hr and prolonged hypotension (P50 yr, CIT>24 hr and prolonged hypotension (P50 yr (57.1% vs 87.2% in 1 yr and 57.1% vs 87.2% in 2 yr), for serum Cr>3.0(50.0% vs 87.1% in 1 yr and 50.0% vs 84.8% in 2 yr), for CIT>24 hr(33.3% vs 86.6% in 1 yr and 33.3% vs 84.3% in 2 yr) and prolonged hypotension(50.0% vs 88.0% in 1 yr and 50.0% vs 84.9% in 2 yr). In the multivariate analysis of these variables, serum Cr>3.0, CIT>24 hr and prolonged hypotension were significant factors for graft outcome. A comparison of the early graft function and the graft survival between high risk group (n=75) - age>50 yr (n=7), serum creatinine>3.0 mg/dl (n=4), CIT>24 hr (n=4), history of hypertension (n=17), use of high dose inotropics (dopa>20 microgram, dobu>15 microgram, n=30), episode of cardiac arrest (n=4), prolonged hypotension (<80 mmHg over 6 hr ,n=8), existence of DIC (n=12) or proteinuria (n=23)- and the ideal group (n=31) did not show any significant difference. We conclude that selective high-risk donors can be used to facilitate the expansion of a small donor pool to overcome the organ shortage. However more efforts to develop the preoperative tests to predict the postoperative graft outcome are neccessary to avoid primary nonfunction and delayed graft function, and to achieve a successful graft survival.