Delayed cutaneous hypersensitivity and human renal allotransplantation.

A group of 154 patients on chronic dialysis has been evaluated by DNCB reactivity. Viewed as a group, these patients exhibit a highly significant decrease in immunologic responsiveness in comparison to normal individuals. However, 19% of patients had an immunologic response to DNCB and 12% an irritant response. This pretransplant DNCB responsiveness correlated significantly with subsequent allograft rejection in 71 renal allotransplant recipients. For example, at 1 year after transplantation graft survival was strikingly different: DNCB- patients, 78%; DNCB+ patients, 29%; and DNCB-IR patients; 20%. Pretransplant recall-antigen testing results in 32 patients did not correlate significantly with subsequent transplant results. Serial posttransplant delayed cutaneous hypersensitivity responses in patients with a positive response to a skin test antigen in the pretransplant period suggest possible usefulness of this technique for detecting rejection in the posttransplant period. DNCB skin testing should be performed in all transplant candidates to evaluate host responsiveness and should aid in future patient management.

Perfusion nephropathy in human transplants.

To determine whether perfusion preservation affected the structure and survival of kidney transplants, we correlated clinical and histologic data in 77 kidneys biopsied one hour after transplantation. Twenty-one of 36 perfusion-preserved kidneys had a glomerular capillary lesion suggestive of intravascular coagulation. None of 41 kidneys preserved by hypothermia alone had this lesion. Presence of the lesion did not correlate with donor or recipient characteristics, warm or cold ischemia time, HLA match, percentage of preformed lymphocytotoxic antibody titers or perfusion characteristics. Of 21 transplants with the lesion, nine required nephrectomy by one month, and one-month serum creatinine was less than 2.0 mg per deciliter in only three of the remaining 12 transplants. We conclude that perfusion preservation may cause pathologic changes that may adversely affect kidney-transplant function. The causes of the pathologic process remain unclear.

Arteriovenous fistulas for dialysis using modified bovine arteries.

Arteriovenous fistulas were created on 21 occasions in 18 patients using an interposed segment of processed bovine carotid artery. In 18 fistulas, there were loops in the femoral region, and in three, they were created in the forearm. Seventeen of 21 fistulas developed a useful patency, with useful patency being achieved in 16 of the 18 patients. This patency is impressive, since it provided life-saving vascular access in these patients who previously had had failure of multiple standard shunts or fistulas. However, there was a high incidence of complications, with 17 of 21 fistulas developing some complication. Ten fistulas spontaneously occluded, but flow was restored in six. Seven significant infections occurred in fistulas of the thigh, with one patient eventually dying from complications. In two patients, major hematomas developed, and in six patients, false aneurysms developed, four of these false aneurysms being clearly associated with infection. Venograms were useful in the arm for demonstrating patency of the vein to be used for the arteriovenous fistula. The bovine interposed segment is a useful alternative in patients with difficult vascular access problems for hemodialysis but should be reserved only for such patients.

Successful allotransplantation of a kidney removed because of ureteral damage in an unrelated living donor.

The use of a kidney removed because of ureteral damage in an unrelated donor has produced a well functioning renal allograft in the transplant recipient. The kidney demonstrated calicectasis and hydronephrosis on an excretory urogram before removal of the ureteral cutaneous fistula. An excretory urogram performed 8 months after the renal allotransplantation of this kidney shows prompt function of a delicate collecting system without any residual calicectasis. This case emphasizes the need for us to explore the possible use of free kidneys removed from living unrelated donors for non-neoplastic diseases of the ureter.

Management of foot conditions of the diabetic patient.

Twenty-five years' experience in the management of the diabetic foot is reviewed. Diagnostic aids and surgical principles which proved worthwhile in preventing major amputations are stressed.

In vivo suppression of the immune response to alloantigen by cholera enterotoxin.

The immune response of C57BL/6 mice to allogeneic (DBA/2) mastocytoma cell suspensions was profoundly suppressed by intraperitoneal administration of 1 mug cholera enterotoxin 4 days after antigenic stimulation. The immune response assayed 11 days after antigen showed decreased cytolytically active thymusderived (T) lymphocytes and markedly depressed serumagglutinating titers. A comparable suppression of the immune response to skin allografts (DBA/2-->C57BL/6) was also effected by cholera toxin administration, although there was no prolongation of allograft survival. The mechanism of the immune suppression is apparently related to the known adenylate cyclase stimulatory activities of choleragen.