Steroid-resistant rejection in kidney-transplanted patients: is ATG treatment for three or ten days preferable?

We carried out a randomized prospective trial to compare a 3-day with a 10-day course of antithymocyte globulin (ATG)-(Fresenius) for treatment of steroid-resistant rejection after renal transplantation. The aim was to study whether a short 3-day course was as safe and effective as the longer 10-day treatment. Thirty patients over a 3-year period were included. Patients that did not respond to treatment after 3 days received additional ATG from day 5 to day 10. The graft survival and the proportion of rejections reversed with the treatment were compared. Fifty percent responded promptly in the 3-day group and a further 29% after additional treatment. In the 10-day group, 62% responded to the treatment. There was no significant difference between the groups. We, therefore, suggest that the standard antirejection treatment with ATG could be shortened without an increased risk of graft failure.

Transplantation of the diabetic in 1994. A personal view.

Kidney transplantation should be tried in all diabetic patients with end stage nephropathy, provided there are no definitive contraindications. Pancreas transplantation can be tried in singular well defined patients in institutions actively involved in adequately related research and development.

Factors influencing anaemia in dialysis patients. A special survey by the EDTA-ERA Registry.

The European Dialysis and Transplantation Association-European Renal Association (EDTA-ERA) Registry conducted a special study on anaemia in dialysis patients because it seemed important to elucidate the various factors that influence the degree of anaemia and the use of regular transfusions in dialysis patients before the introduction of recombinant human erythropoietin (rHuEpo) for larger groups of patients. In a 20% sample of all patients recorded to have been dialysed throughout 1987, statistically significant associations could be found by multifactorial analysis between haemoglobin (Hb) concentration and age, sex, primary renal disease, type of treatment, hours of dialysis per week, and number of years on renal replacement therapy. The type of dialyser membrane did not seem to play a role (although there was weak evidence of an effect of the dialyser). Mean Hb concentration for dialysis patients differed between countries as did the transfusion policy. In view of the high costs of the rHuEpo treatment and potential side-effects, factors such as method of dialysis and hours of haemodialysis per week should be taken into consideration in the treatment of anaemia in dialysis patients.

Successful pregnancies in women on renal replacement therapy: report from the EDTA Registry.

This study reports the geographical incidence of successful pregnancies in women on renal replacement therapy (RRT) and related information on gestation and clinical status of newborns. The impact of successful pregnancy on graft function was assessed by means of a retrospective case-control study. Since 1977 special questionnaires have been sent to each dialysis and transplant centre which reported babies born to mothers on RRT on the yearly centre questionnaire. After 10 years of data collection, a total of 490 pregnancies and 500 babies were available for analysis. A percentage of 88.4 of the babies were born to mothers with a functioning graft, 11.2% to mothers on chronic haemodialysis, and the remaining 0.4% to mothers on CAPD. Almost 50% of all successful pregnancies were reported from the UK. The number of successful pregnancies increased steadily and in parallel with the increasing number of females of childbearing age with a functioning renal transplant. The majority of mothers delivered at age 24-32. For transplanted mothers delivery occurred most commonly during the 3rd and 4th year after successful transplantation. In approximately 85% of cases the duration of pregnancy was shorter than the lower 10th percentile of normal. Birthweight was reduced in accordance with gestational age. Newborn mortality was 1.8%. Fifty-three mothers with a successful pregnancy in 1984-1987 were computer matched with controls according to a number of criteria. The serum creatinine concentration recorded in coded form at the end of each year on the individual EDTA patient questionnaire was used to assess changes in graft function.(ABSTRACT TRUNCATED AT 250 WORDS)

Rehabilitation of young adults during renal replacement therapy in Europe. 1. The presence of disabilities.

The aim of this study was to analyse rehabilitation during RRT in 617 young adults from different European countries who started dialysis or transplantation before the age of 15 years. The data were derived from the EDTA Registry patient data files and a special questionnaire that was sent to centres reporting to the EDTA Registry. The duration of RRT was more than 10 years in 63% of patients. Fifty-four percent were living with a functioning graft and 46% were on dialysis. The prevalence and severity of motor, hearing, sight, and mental disabilities were analysed retrospectively. They were found to vary according to primary renal disease and method of treatment. One-third of patients had one or more disabilities at the start of RRT. Although disability status had changed in many patients by 31 December 1986, some disability remained in one-third of the patients available for study. Disabilities were recorded as mild in the majority of patients. Both improvement and worsening of motor and mental disability occurred more often than changes of hearing capacity and sight. It is concluded that prevention and treatment of disabilities need special attention in children and young adults on RRT in order to improve rehabilitation.

Rehabilitation of young adults during renal replacement therapy in Europe. 2. Schooling, employment, and social situation.

The educational status, employment rate and social situation were studied in 617 patients between 21 and 35 years of age who started renal replacement therapy (RRT) as children. The data were derived from a special questionnaire concerning disability and rehabilitation sent to dialysis and transplant centres reporting to the EDTA Registry. Fifty-six percent of patients completed secondary school and one in three went on to vocational training. Eleven percent of patients attended university, and 16% were reported to have gone to a special school for the handicapped. Up to one-third of patients who attended different school types failed to complete their education. There were notable geographical differences in schooling and in employment. Fifty-six percent of all patients were employed. Lack of schooling was considered to be a major reason for unemployment. Sixty-one percent of patients with disabilities and 34% without disabilities were receiving invalidity payments. The place of residence of these patients aged 21-35 was usually the parental home. Compared to the general population of similar age, only a few patients were married (13.5% of the total study group) and 8% had children. In summary, the present report shows that the major factors influencing rehabilitation on RRT are the presence of disabilities, the method of treatment, geographical factors, duration of RRT, and the underlying primary renal disease.

Renal transplantation in diabetic patients with or without simultaneous pancreatic transplantation 1986: data from the EDTA Registry.

This report summarises the outcome of 90 combined kidney/pancreatic grafts performed in Europe in 1986. Data for the combined kidney/pancreas grafts were obtained by a special questionnaire. The one-year patient and kidney graft survival is compared to the results of a group of 389 patients with diabetic nephropathy on the EDTA Registry data file who received kidney grafts alone. The recipients of combined kidney-pancreas grafts were younger, whereas a greater proportion of males received kidney graft alone. Patient survival at one year after transplantation was similar: 89% in recipients of combined transplants compared to 90% in recipients of kidney grafts alone. Kidney graft survival was 78% at one year for recipients of combined grafts versus 76%. It is concluded that pancreas transplantation has little effect on the fate of concomitant kidney grafts. The procedure should-in experienced hands and in selected patients-be almost as safe as kidney grafting alone.

Blood lymphocyte subsets in ATG-treated and allografted rats.

A single dose of rabbit antithymocyte globulin (ATG) was given as the sole immunosuppressive therapy in a model of strong MHC barrier rat heart allotransplantation. PVG/c hearts transplanted to Wistar/Kyoto (WKy) rats resulted in long-term surviving (LTS) grafts and cell-mediated lympholysis (CML) unresponsiveness in 50% of the animals. The effects of ATG treatment on the peripheral blood lymphocyte subsets were studied by flow cytometry. The absolute T-lymphocyte levels decreased to less than 5% and were normalized after 2 weeks. CD8-positive cells were normalized within 1 week, whereas CD4- and CD5-positive cells remained low. Rats with LTS grafts had low levels of all T-lymphocyte markers, especially the CD4- and CD5-positive cells. Rats rejecting their grafts showed an eightfold increase in levels of CD8- and CD5-positive lymphocytes and a twofold increase in levels of CD4-expressing lymphocytes. It is concluded that ATG treatment causes the immediate elimination of large lymphoid populations as well as long-lasting immunomodulation detectable in peripheral blood.

ABO-incompatible kidney transplantation (A2 to O). Qualitative and semiquantitative studies of the humoral immune response against different blood group A antigens.

The humoral immune response against blood group A antigens with different core saccharide structures has been investigated in four blood group O recipients transplanted with kidneys from two blood group A2 donors. Radioimmunoassay and thin-layer chromatogram binding assay studies showed that different individuals responded differently to the same antigenic stimulus. Antibodies were produced in the recipient that bound to the terminal trisaccharide of the blood group A antigens. In some cases antibodies that bound to a larger antigen epitope, including the fourth and fifth sugar in the polysaccharide core chain, also occurred. Immunoglobulin class-specific, as well as subclass specific, responses were seen. The antibody response in the blood group O recipients receiving an A2 graft seem to be dependent on the antigenic expression in the transplanted kidney. In view of the recent findings of individuality of A antigen expression in kidneys within the A1 and A2 subgroups, an extended typing of A2 donors may be important. The humoral immune response in the recipient may also be dependent on earlier contacts with ABO incompatible pregnancies, vaccinations, or infections. A possible correlation between pre- and posttransplant findings was noted in one case and deserves further notice.

Case control study on dialysis arthropathy: the influence of two different dialysis membranes: data from the EDTA Registry.

In a retrospective case control study the prevalence of signs and symptoms of dialysis osteoarthropathy was analysed. Cases and controls had received over 9 years of maintenance haemodialysis uninterrupted by peritoneal dialysis or transplantation. The cases comprised 55 patients treated predominantly with polyacrylonitrile (AN69) dialysers. They were compared to a matched group dialysed exclusively with cellulosic membranes. Over 60% of all patients, cases and controls, showed one or more signs of disabling osteoarthropathy, with joint pains occurring more frequently in the older age groups. Twenty-seven of the 55 cases who had received less than 2 years of cellulosic membrane dialysis followed by 7-12 years of AN69 dialysis tended to have a lower prevalence of joint pains, carpal-tunnel syndrome and bone cysts. However, no statistically significant differences were obtained compared to the matched control group dialysed exclusively on cellulosic membranes (mostly cuprophane). The remaining 28 cases, who had been treated for more than 2 years with cellulosic membranes preceding the longer treatment period with polyacrylonitrile dialysers, showed a prevalence similar to that of their cellulosic controls. This study thus shows little, if any, influence of the two types of membranes on the prevalence of signs and symptoms of beta 2-microglobulin amyloidosis.

The use of continuous peritoneal dialysis in Europe for the treatment of children with end-stage renal failure: data from the EDTA Registry.

The demographic data on the use of continuous peritoneal dialysis in Europe for children starting renal replacement therapy under the age of 15 years was obtained from data collected by the Registry of the European Dialysis and Transplant Association--European Renal Association (EDTA Registry) on individual patient questionnaires 1980-1986. Continuous ambulatory peritoneal dialysis (CAPD) and its variants appeared to be increasingly utilised as treatment for children with end-stage renal failure (ESRF) and accounted for approximately 25% of all renal replacement therapy (RRT). Important differences in its use in various European countries are demonstrated. The proportional contribution of CAPD to treatment was higher during the first year of RRT and gradually decreased thereafter. No significant sex differences existed in the use of this treatment. Approximately 70% of all patients on CAPD were older than 6 years of age, but it is in those under 6 years that the highest proportion are put on CAPD as first method of treatment for end-stage renal failure. The most common cause of abandonment of this treatment was peritonitis, which contributed 50% of the drop-out rate.

Kidney transplantation in primary oxalosis: data from the EDTA Registry.

This paper reports the results of 98 first kidney transplantations in patients with oxalosis as the primary renal disease as recorded by the EDTA Registry. There were 79 patients who received a cadaveric (CAD) graft and 15 patients with a living related donor (LRD) graft; the type of donor was not recorded for four patients. Initial graft survival appeared to be better after LRD as compared to CAD grafts but at 3 years the poor survival was similar with 23% for LRD and 17% for CAD grafts. CAD graft survival did not differ between children and adults and was not affected by the waiting time on dialysis. A slight improvement was observed in grafts performed in the years 1983-1986 as compared to grafts performed in earlier years. The causes of failure reported were mainly rejection (33%) and recurrence of primary renal disease (31%). In view of the poor results related to recurrence of oxalosis in the graft, the potential of combined kidney and liver transplantation is discussed.