Incidence of cytomegalovirus-infection after renal transplantation and first experiences with prophylactic hyperimmunoglobulin.

Incidence and clinical symptomatology of CMV-infection was investigated in 83 patients, who received cadaveric renal transplants in 1982 and 1983. CMV-antibody status was determined using an ELISA-technique, 43 of the 83 patients (52%) were seronegative, and 40 (48%) were seropositive for CMV before transplantation. Seroconversion (i.e. primary CMV-infection) or an increase in titre (i.e. reactivation or reinfection) was found in 18 cases (42% and 45%, respectively) in both groups. 89% of all infections occurred within the first 3 months. Clinical symptomatology was much more severe in the group with primary CMV-infection; all cases with atypical pneumonia (n = 8) and both fatal cases belonged to this group. Preformed CMV-antibodies thus appeared to prevent severe syndromes associated with CMV-infection. Therefore a randomized controlled study was started in 1984 in order to investigate the efficacy of an i.v. applicable CMV-hyperimmunoglobulin passively administered prior to the transplant procedure. The passive immunization was not capable of preventing CMV-infection in every case: 2 (late) seroconversions did occur, but in both cases subclinical infections were diagnosed, whereas in the control group CMV-infections were regularly associated with typical clinical complications (prolonged fever, liver damage, leucopenia etc.). Thus prophylactic CMV-hyperimmunoglobulin seems to be capable of preventing the occurrence of severe CMV-syndromes post transplantation. The study is being continued.

Therapy and monitoring of hypersiderosis in chronic renal insufficiency.

In RDT hemosiderosis appears to be an inevitable complication only in the small number of patients in need of frequent transfusions. To prevent clinical consequences (e.g. cardiomyopathy) known from polytransfused patients without renal disease, transplantation should be considered in RDT patients in need of frequent transfusions. Iron substitution - preferably oral - to replace dialysis-related iron loss does not cause clinically significant hemosiderosis provided iron stores are monitored adequately. A sufficient method of controlling iron stores in RDT patients under iron substitution or regular transfusion therapy is a twice annual determination of serum ferritin concentration. The treatment of choice for hemosiderosis in nontransfused RDT patients is discontinuation of iron substitution. When polytransfused RDT patients with severe hemosiderosis cannot be transplanted and submitted consecutively to phlebotomy, DFO treatment is indicated. Quantitative data regarding optimal dosage and application of DFO in RDT patients are not yet available. Constant infusion of DFO during hemodialysis may be superior to bolus application.

Renal allograft survival in patients transfused perioperatively only.

We investigated in a prospective study the effects of perioperative blood transfusions on the outcome of renal transplantation. All patients (n = 105) receiving their first cadaveric renal allograft were transfused perioperatively (i.e. 0-6 hours before transplantation) with two units of non-washed, unfiltered packed red cells. Forty-eight were transfused perioperatively only; 57 patients had received blood earlier and thus were transfused pre- and perioperatively. Graft survival one and two years post-transplant was 79 per cent at both time intervals in the group transfused perioperatively only, and 85 per cent and 74 per cent in the pre- and peroperatively transfused group. No adverse effects were observed concerning perioperative transfusions. In patients transfused perioperatively only, acceptable graft survival rates are obtainable. In these patients the risk or presensitisation is avoided, and thus their chance of successful transplantation increased.

Improved graft prognosis by treatment of steroid resistant rejections with ATG and plasmapheresis.

Conventional therapy of acute rejection is almost exclusively based on increased steroid dosage, however, a considerable number of grafts undergo irreversible steroid resistant rejection (SRR). We investigated in a prospective study the effects of antithymocyte globulin (ATG) and plasmafiltration (PF) in cases of SRR. Acute interstitial rejections were treated with ATG, acute vascular rejections with PF. Thirty-nine of 42 (93%) cases of SRR were reversed by these forms of therapy. In 68 recipients of first cadaveric renal allografts actuarial one year graft survival has improved to 88 (+/- 5) per cent since the introduction of ATG and PF for SRR. Severe side effects or increased mortality were not observed, none of the patients with either form of therapy died. Thus ATG and PF are valuable adjuncts in the treatment of SRR.

Two survivors of severe paraquat intoxication by "continuous hemoperfusion".

"Continuous hemoperfusion" (8 h/day for 2--3 weeks) was performed in two patients suffering from severe paraquat intoxication. On account of paraquat plasma concentrations a fatal outcome due to pulmonary fibrosis would have been expected in both cases. However, both patients survived following "continuous hemoperfusion" therapy. Coated activated charcoal seems to have a higher affinity for paraquat than lung tissue.

Occult blood loss and iron balance in chronic renal failure.

In 38 patients with chronic renal failure total daily blood loss and intestinal iron absorption were determined by means of a whole-body counter and radioiron. Bone marrow iron content was measured histochemically. Mean daily blood loss (corrected for laboratory blood sampling) and iron absorption were significantly higher than in normal controls. Bone marrow iron content was reduced in 46% of the patients. The results prove that gastrointestinal blood loss in patients with chronic renal failure is of such magnitude that negative iron balance results.