Incidence of new-onset hypercholesterolemia in renal transplant patients treated with FK506 or cyclosporine.

In this study, we compare cholesterol levels during the first year after renal transplantation in FK506 (Prograf)- and cyclosporine-treated patients matched for cumulative first-year steroid dose and hypercholesterolemia risk factors. All patients had pretransplant cholesterol levels < 200 mg/dl. At 3 months posttransplant, 68% of the cyclosporine-treated patients had at least one cholesterol level greater than 200 mg/dl compared with 30% of the FK506-treated patients (P < 0.05). At the end of the year, 26% of FK506- and 67% of cyclosporine-treated patients remained hypercholesterolemic (P < 0.05). We conclude that cyclosporine has inherently more effect on cholesterol levels than FK506 during the first year after kidney transplantation.

Risks of transplanting kidneys from hepatitis B surface antigen-negative, hepatitis B core antibody-positive donors.

BACKGROUND: As the number of patients on the United States kidney transplant list increases, investigation into the utility of transplanting organs formerly considered marginal or undesirable has intensified. Using kidneys from hepatitis B surface antigen (HBsAg)-positive donors is thought to place recipients at excessive risk of graft failure, morbidity, and mortality. However, the risks of using kidneys from HBsAg-negative but hepatitis B core antibody (HBcAb)-positive donors have not been defined. METHODS: Between 1990 and 1994, our group transplanted 1067 cadaveric kidneys, including 38 from HBsAg(-)/HBcAb(+) donors. Of these 38 kidneys, 27 were transplanted into HBcAb(-) recipients (group 1) and 11 were transplanted into HBcAb(+) recipients (group 2). Group 1 and 2 patients received no hepatitis immunoglobulin therapy after transplantation and received the same immunosuppression and rejection therapies as recipients of kidneys from HBcAb(-) donors. RESULTS: After transplantation, none of the group 1 patients became HBsAg(+), three became hepatitis B surface antibody (HBsAb)-positive, and two became HBcAb(+). Of the group 2 patients, none became newly HBsAg(+) or HBsAb(+). No patient receiving a kidney from an HBsAg(-)/HBcAb(+) donor developed signs or symptoms of clinical hepatitis B. Graft and patient survival rates were similar in both groups and similar to the rates of the 1029 recipients of kidneys from HBcAb(-) donors. CONCLUSIONS: Recipients of kidneys from HBsAg(-)/HBcAb(+) donors are at a small risk of hepatitis B seroconversion but are at no excess risk of graft failure or short-term morbidity or mortality.

Outcome of en bloc and single kidney transplantation from very young cadaveric donors.

BACKGROUND: The optimal use of very young cadaveric kidneys (from donors less than 4 years old) remains controversial. High rates of technical complications and poor functional results compared with adult donor kidneys have been reported. The use of en bloc transplantation to overcome these problems has been advocated, although en bloc transplantation halves the number of potential transplants from very young donors. METHODS: We studied the technical and functional results of 91 transplants from very young donors performed at our institution between 1984 and 1995. This included 59 single and 22 en bloc procedures involving first transplants and 7 single and 3 en bloc procedures involving retransplantation. Individual surgeon preference dictated the use of either the single or en bloc technique. Kidneys smaller than 6 cm tended to be transplanted en bloc, and lighter patients were generally given preference for receiving pediatric kidneys. Patients received sequential cyclosporine-based quadruple immunosuppression. RESULTS: En bloc kidneys had a 1-year and 5-year graft survival of 82% and 70%, respectively. Single kidneys had a 1-year and 5-year graft survival of 64% and 40%. Kidneys that avoided acute rejection episodes and that were transplanted into heavier or male recipients had better long-term survival. Kidneys from donors less than 2 years old did poorly whether transplanted en bloc or singly. Better HLA matching improved short-term, but not long-term, graft survival, whereas cold ischemic time did not have statistically significant association with differences in graft survival. Eleven percent of the transplants had ureteral leaks, but only one kidney was lost. Ten transplants had vascular complications leading to graft loss, whereas two episodes of arterial stenosis were successfully treated with percutaneous angioplasty. CONCLUSIONS: En bloc transplantation optimizes the outcome of transplantation with very young kidneys. We recommend induction therapy and cyclosporine immunosuppression with cyclosporine levels similar to adult target levels to minimize rejection episodes and, thus, improve outcome. These kidneys should be distributed nationally, because better HLA matching is associated with improved short-term graft survival. Our high ureteral leak rate indicates that alternatives to unstented ureteroneocystostomy should be considered.

Library faculty role in problem-based learning: facilitating small groups.

Since 1986, the library faculty of the McGoogan Library of Medicine at the University of Nebraska Medical Center (UNMC) has participated in small group activities during the week-long orientation for first-year medical students. This involvement paved the way for library faculty members to act as facilitators for small groups of medical students within the new problem-based learning (PBL) curriculum introduced in 1992 by the College of Medicine. The UNMC curriculum consists of traditional PBL groups as well as Integrated Clinical Experience (ICE) small groups. The ICE groups provide opportunities for discussion of the social and behavioral issues that arise in medicine, with the majority of the sessions designed to give students interviewing practice with simulated patients. The ICE small groups meet once a week with either one or two facilitators. Several library faculty members act as facilitators for ICE groups. As a result of this involvement, librarian contacts with College of Medicine faculty have grown in number and depth, there has been a corresponding increase in related activities with the first- and second-year medical students. Participation in ICE groups has caused some difficulties with respect to library work schedules, but it has been immensely rewarding and enriching in terms of professional growth. This paper describes the UNMC curriculum, the evolution and extent of the librarians' involvement, and the future involvement, ramifications, and challenges envisioned for McGoogan faculty and their medical library colleagues.