Prevention of hyperacute rejection by removal of antibodies to HLA immediately before renal transplantation.

BACKGROUND: Many patients with circulating antibodies to human leucocyte antigens (anti-HLA) are highly sensitised against renal transplantation and are liable to immediate graft loss through hyperacute rejection. Our aim was to find out whether removal of anti-HLA immediately before renal transplantation prevented hyperacute graft rejection. METHODS: 13 highly sensitised patients underwent cadaveric renal transplants immediately after immunoadsorption (IA) treatment to remove anti-HLA. Before IA, 12 patients had a positive crossmatch against donor cells either by cytotoxic or flow-cytometric assay; results for one patient were equivocal. FINDINGS: Renal biopsy samples were obtained 20 min after removal of the vascular clamps in nine patients. There was no evidence of hyperacute rejection in six of the nine patients; the other three patients showed glomerular thrombosis but no other evidence of hyperacute rejection. Two of these three grafts were functioning at 31 months of follow-up. Six episodes of acute rejection occurred in five patients during the first month after transplantation and overall there were 13 rejection episodes in nine patients. At latest follow-up (median 26 months, range 9-42), 12 of 13 patients were alive and seven of 13 grafts were surviving with a median plasma creatinine concentration of 185 mumol/L (range 106-296) in the functioning grafts. No graft was lost as a result of classic hyperacute rejection. INTERPRETATION: Immediate pretransplant IA can prevent hyperacute rejection and provide an opportunity for successful transplantation in highly sensitised patients.

Transplant renal artery stenosis in 77 patients--does it have an immunological cause?

Transplant renal artery stenosis (TRAS) is a common complication after transplantation and is an important cause of graft dysfunction. Damage from graft rejection, trauma, and atherosclerosis have been implicated as possible causes. We reviewed all 917 patients transplanted in our unit since 1978 to study the prevalence, clinical features, and possible causes of TRAS. Seventy-seven patients with TRAS were identified. The detected incidence was 2.4% before the introduction of color doppler ultrasonography (CDU) and rose to 12.4% after CDU was introduced in 1985, giving an overall incidence of 8.4% during a mean follow-up period of 6.9 years. The TRAS group was compared with a control group of 77 transplanted patients matched for age, year of transplant, sex, and number of previous grafts. Mean ages for the study and control groups were 43.6 +/- 15 and 44.8 +/- 13.7 yr. A total of 25% of cases of TRAS were diagnosed within the first 8 wk of transplantation and in 60% within the first 30 wk (median = 23 wk). All patients were treated with angioplasty, 28 patients had recurrence of TRAS requiring multiple angioplasties (maximum 5) and 1 went on to have surgery. Angioplasty resulted in a significant fall in plasma creatinine. Patient and graft survival were significantly worse in the TRAS group: 69% vs. 83% (P < 0.05) and 56% vs. 74% (P < 0.05) (TRAS vs. Control), respectively. There was a significantly higher incidence of rejection, especially cellular rejection in the TRAS group, 0.67 vs. 0.35 episodes per patient (P < 0.01) (TRAS vs. Control). Recurrence but not occurrence of TRAS was associated with the use of cyclosporine.

Outcome of renal transplantation in hepatitis BsAg-positive patients.

Renal transplantation of patients with previous or ongoing hepatitis B virus infection has been tempered with a concern that immunosuppression may lead to viral replication and progressive liver damage. However, renal transplantation as therapy for end-stage renal failure in these patients improves quality of life and reduces the risk of body fluid exposure to their carers. To assess the long-term outcome of renal transplantation in hepatitis-BsAg-positive patients a retrospective study was carried out on the patients transplanted in this unit since 1969. Seventy-six patients received 98 grafts up to December 1991; follow-up was available on 68. Thirty-one of the 68 patients died; the causes of death were infective 23, cardiovascular 6, liver failure 4, pancreatitis 2, aspiration 1, GI haemorrhage 1, and stopped therapy 1. Serological markers of hepatitis B virus infection did not correlate with outcome. The risk of developing liver failure after renal transplantation appears small in the hepatitis-BsAg-positive patients and no patient should be denied a renal transplant on the basis of serological tests.

The influence of recipient and donor age on the outcome of renal transplantation.

This paper assesses the impact of age on the outcome of cadaveric renal transplantation. Data are presented on 99 consecutive patients undergoing first renal allografts at one unit. Patients are divided into those aged less than 50 (n = 53), patients between 50 and 60 (n = 16), and those aged 60 years and over (n = 30). There was no significant difference in graft survival at one year between the three groups. There was however an increased mortality with increasing recipient age (1.9%, 12.5% and 20.0% respectively for each age group). The effect of increasing donor age on graft survival was also studied. Graft survival at two years for first grafts was not influenced by donor age. We conclude that age alone is not a criterion for exclusion of patients from transplant programs. In addition we provide data to support the use of elderly donors as a potential source of cadaveric renal grafts for certain patients.

Congenital hepatic fibrosis and polycystic kidney disease; Role of porta-caval shunting and transplantation in three patients.

Three patients with congenital hepatic fibrosis and childhood-type autosomal recessive polycystic kidney disease are reported. Portal hypertension in two of the children was decompressed surgically by lieno-renal shunting, and the renal failure in two children has been successfully treated with renal transplantation. Prophylactic porta-caval shunting followed by renal transplantation is ideally suited to the sequence of events occurring clinically in the intermediate form of this condition, preventing complications of bleeding from oesophageal varices and hyperplenism. The relationship of congenital hepatic fibrosis with the various forms of polycystic kidney disease is discussed and classified.

Risks and benefits of bilateral nephrectomy: an analysis of 134 cases.

In a retrospective survey of 134 patients undergoing bilateral nephrectomy from 1969 to 1980 it was found that the commonest indications were hypertension (60%) and infection/reflux (22%). Operation in hypertensive dialysis patients was followed by a fall in blood pressure in 70% (SE 9%) at one and 3 months while normotensive patients having their kidneys out for other reasons had a 47% (SE 11%) incidence of hypertension at one month and 7 out of 10 were still hypertensive at 3 months. When operation was performed in transplanted patients, 7 of 10 hypertensives had a fall in pressure, one of 6 normotensive persons had an increase, an use of antihypertensive drugs fell from 13/16 to 4 of 16 patients. The mortality was 10.4% (SE 2.6%) overall, the mortality of operations which included an unplanned splenectomy was significantly higher. There were 34 other complications in 25 patients. Complications, but not deaths, were more frequent in operations performed in dialysis patients rather than at the same time as, or after, a transplant. Over 12 years the ratio of bilateral nephrectomy to renal transplant operations has fallen from 8% (1969-1971) to 18% (1978 to present). The decrease is partly due to a fall in the number of operations for hypertension in dialysis patients and may be related to the appearance of beta-blocker and new vasodilator drugs.

The prevalence of psychiatric illness among patients on home haemodialysis.

An entire population of 32 patients on regular dialysis treatment (RDT) in their own homes were ranked according to their present mental state as assessed by a standardized semi-structured interview. The point-prevalence of psychiatric morbidity was 31% which compares closely with that of patients attending a general practitioner's surgery who were assessed by the same method. The 10 patients who were psychiatrically ill had more organic symptoms and their spouses were less able to tolerate RDT in the home.

Survival on home haemodialysis: its relationship with physical symptomatology, psychosocial background and psychiatric morbidity.

An entire group of 32 home dialysis patients from one hospital renal unit was assessed for psychiatric morbidity on a standardized interview of proven reliability. A rating of physical symptomatology and an enquiry into the childhood and psychosocial background were made at the same time. Psychiatric morbidity, physical symptomatology and a history of good relationships with both natural parents in childhood were inter-related. They were all related to survival on haemodialysis 3 1/2 years later. Survival was also associated with a coping spouse and full-time employment or housework by the patient. These findings are discussed in the light of current concepts of the psychosocial setting for physical illness.