Hand-assisted laparoscopic donor nephrectomy. Ascending the learning curve.

BACKGROUND: The hand-assisted approach to laparoscopic donor nephrectomy (LDN) might minimize the learning curve and shorten both the operation and the warm ischemia time. Our initial results from hand-assisted LDN are presented and compared with data from the literature. METHODS: From January to September 2000, ten hand-assisted LDNs of the right kidney were performed. RESULTS: The median operation time was 140 min (range, 120-400 min), and the warm ischemia time was 2.5 min (range, 1-4 min). There were no conversions. Postoperative morbidity included one urinary tract infection. All but one patient returned to a normal diet within 48 h. Opiates were needed a maximum of 48 h. One recipient experienced initial loss of graft function as a result of unknown causes. CONCLUSIONS: Even at the beginning of the learning curve, operation time and warm ischemia time are significantly reduced by the hand-assisted approach, as compared with conventional LDN.

Expression of granzyme B during primary cytomegalovirus infection after renal transplantation.

CD8+ T cells employ granzyme B (GrB) to induce apoptosis in target cells. Increased expression of GrB has been put forward as a diagnostic marker in transplant rejection and viral infection. Three-color flow cytometric analysis revealed that peripheral blood CD8+ T lymphocytosis during primary cytomegalovirus infection after renal transplantation resulted from expansion of a CD8+GrB+CD62L+ T cell subset that was almost absent during stable transplant function or acute rejection. This expansion coincided with a temporary increase in systemic soluble GrB (sGrB) levels. No such increase was observed during stable transplant function or acute rejection. Thus, the primary immune response to cytomegalovirus infection is accompanied by appearance of CD8+GrB+CD62L+ T cells and increased sGrB levels in the peripheral blood compartment. Determination of the latter may provide a novel approach for monitoring viral infections.

The effect of renal transplantation on hyperhomocysteinaemia in dialysis patients, and the estimation of renal homocysteine extraction in patients with normal renal function.

BACKGROUND: The pathophysiology of hyperhomocysteinaemia in chronic renal failure (CRF) is unknown. Possible mechanisms are decreased renal homocysteine (Hcy) catabolism or inhibition of extrarenal Hcy metabolism by uraemic toxins. METHODS: We studied the short-term effect on plasma Hcy concentration of improvement of renal function after successful kidney transplantation (n = 8), and determined renal Hcy extraction by measurement of total Hcy in arterial and renal venous blood in 7 cardiac patients with normal renal function. RESULTS: Post-transplantation, plasma Hcy decreased with improving renal function. In the cardiac patients, no significant renal Hcy extraction could be demonstrated, but tubular disposal of the filtered load could not be excluded. CONCLUSIONS: Because loss of such renal metabolism could lead to hyperhomocysteinaemia in CRF, it is necessary to determine the renal extraction of free Hcy in subjects with normal renal function to further investigate renal homocysteine metabolism.

Administration of OKT3 as a two-hour infusion attenuates first-dose side effects.

BACKGROUND: Use of the murine CD3 monoclonal antibody OKT3 is limited by first-dose side effects, which are thought to be caused by the release of inflammatory mediators. Because these processes might be influenced by the speed of administration, we compared a 2-hr OKT3 infusion with the bolus infusion usually applied nowadays. METHODS: Eighteen renal allograft recipients were prophylactically treated with OKT3 and randomized to receive the first dose either as a 2-hr infusion or as an intravenous bolus infusion. Clinical side effects score and the occurrence of complement activation, cytokine release, and activation of neutrophils were determined. RESULTS: Two-hour infusion of OKT3 completely prevented the occurrence of dyspnea, reduced the incidence of other side effects, and attenuated complement activation. Cytokine release and depletion of peripheral blood lymphocytes were similar in both groups. CONCLUSIONS: Thus, complement activation seems to play an additional role in the development of side effects after the first OKT3 dose.

Toxicity of OKT3 increases with dosage: a controlled study in renal transplant recipients.

In the present study we prospectively compared side effects occurring in 12 patients after the first administration of low-dose OKT3 (0.5 mg twice daily) induction therapy with those in 10 patients who were treated with a conventional dose of OKT3 (5 mg daily) for acute rejection. We also investigated cytokine release and activation of complement and neutrophils as all of these are held responsible for OKT3-induced side effects. Low-dose OKT3 resulted in a significantly decreased side effects score compared to that after a conventional dose of OKT3 (1.8 vs 5.1, p = 0.0006). Following the first administration of low-dose OKT3, TNF peak levels were significantly lower than after a conventional dose of OKT3. In contrast to our data on conventional dose OKT3 treatment, the first administration of low-dose OKT3 did not induce complement activation as reflected by C3a and C4b/c levels in plasma. Finally, the increase in neutrophil degranulation products lactoferrin and elastase-varies; is directly proportional to 1-antitrypsin was much less following 0.5 mg OKT3 than following 5 mg. We conclude that OKT3-induced toxicity is dose-dependent and is mediated not only by cytokine release but also by activation of complement and neutrophils.

Pretreatment with divided doses of steroids strongly decreases side effects of OKT3.

The aim of this study was to attenuate side effects of OKT3 by variation of the time interval between administration of corticosteroids and OKT3 in renal allograft recipients. In view of a maximal lymphocytopenia at six hours following MPNS, we postulated a greater preventive action on side effects from administration of methylprednisolone (MPNS) at six hours preceding the first dose of OKT3 compared to administration immediately before. Two groups of renal transplant patients treated for acute rejection with 5 mg OKT3 were studied. Ten patients received 500 mg MPNS six hours and ten patients one hour before administration of OKT3. We measured clinical side effects, body temperature, TNF and IL-6. There were no differences between the two groups regarding clinical side effects and peak body temperatures. However, MPNS administered six hours before administration of OKT3 diminished TNF release; MPNS one hour before decreased IL-6 release. We studied an additional group of six patients receiving 250 mg MPNS six hours before, followed by 250 mg one hour before OKT3. This group experienced significantly less side effects and lower body temperature. In addition, IL-6 levels were significantly decreased. We conclude that two times 250 mg MPNS administered six hours and one hour before the first administration of OKT3 effectively attenuates adverse reactions following administration of OKT3.

In vivo effects of IgA and IgG2a anti-CD3 isotype switch variants.

Side effects after the first administration of OKT3, a murine anti-CD3 monoclonal antibody (mAb) of the IgG2a class, are largely attributed to the release of cytokines as a result of T cell activation caused by interaction with Fc receptors (FcR) on human monocytes. As human monocytes possess FcR for murine IgG2a but not for IgA, it is expected that an anti-CD3 mAb of the IgA class causes less side-effects than an IgG2a anti-CD3 mAb of the same idiotype. To test this hypothesis we treated 20 renal transplant patients prophylactically with either IgG2a or IgA anti-CD3 mAb in a prospective randomized double-blind study. The patients received 0.5 mg anti-CD3 mAb, either IgA (T3.A) or IgG2a (T3.G2a), twice daily during 10 d. Rejection incidence after T3.A and T3.G2a was not significantly different. Side effects score after the first administration of mAb was significantly less after T3.A than after T3.G2a (0.7 vs 2.7, P = 0.002). IL-6 and gamma IFN levels increased significantly at 3 h after T3.G2a, but not after T3.A. The TNF peak level occurring at 1 h after T3.A was much lower than after T3.G2a. In plasma, complement and neutrophil activation products only increased after T3.G2a and not after T3.A. Both T3.A and T3.G2a resulted in a complete depletion of CD3+ cells, but after T3.A, CD3 depletion was of shorter duration than after IgG2a. Finally, in contrast to T3.G2a, T3.A did not affect coagulation and fibrinolysis. In conclusion, an anti-CD3 mAb of the IgA class causes hardly any cytokine release and less side-effects as compared with its IgG2a switch variant. Provided T3.A is sufficiently immunosuppressive, it is superior to OKT3.

Low-dose OKT3 induction therapy following renal transplantation: a controlled study.

In a prospective clinical study we tested the immunosuppressive properties and toxicity of low-dose OKT3 induction therapy in renal transplant recipients. 50 consecutive renal transplant recipients were alternatingly assigned to low-dose OKT3 induction or prednisolone/cyclosporin. Low-dose OKT3 induction treatment consisted of 0.5 mg OKT3 twice daily for 10 days, initially combined with azathioprine and prednisolone maintenance immunosuppression that was converted to prednisolone/cyclosporin at the end of the course. During a 15-29-month follow-up period, low-dose OKT3 induction therapy was found to reduce significantly the incidence of acute rejections, as compared to the usual prednisolone/cyclosporin maintenance immunosuppression (21 versus 52%, P = 0.02). There also was a tendency towards an improved graft function after low-dose OKT3, although no significance was reached. Furthermore, compared to a historical control group of renal transplant patients in whom acute rejection was treated with 5 mg OKT3 daily, low-dose OKT3 appeared to cause fewer side-effects. We conclude that low-dose OKT3 induction therapy is superior to prednisolone/cyclosporin in preventing acute rejection after renal transplantation and that it is better tolerated than conventional OKT3 treatment.

Serum neopterin/creatinine values correlate with severity of symptoms caused by cytomegalovirus infection in renal transplant recipients.

Serum neopterin/creatinine ratios were longitudinally measured in 86 renal transplant recipients from the day before transplantation until 4 months after transplantation, and the relationship to the clinical symptoms of cytomegalovirus (CMV) infection was studied. Infection with cytomegalovirus occurred in 23 patients, 11 cases of which were due to primary infection. Symptoms caused by CMV infection were more severe in male patients, in patients who had received prior antirejection treatment, and in patients with primary CMV infection. The measurement of serum neopterin/creatinine ratios proved to be a marker for the severity of symptoms caused by CMV infection, as peak values were significantly higher in eight patients with CMV disease than in patients with no or only mild symptoms of CMV infection (P < 0.05). Moreover, in seven out of eight cases of CMV disease, serum neopterin/creatinine ratios started to rise up to 2 weeks before CMV infection was proven by serology.

Impaired fibrinolysis in cyclosporine-treated renal transplant patients. Analysis of the defect and beneficial effect of fish-oil.

Cyclosporine treatment has been associated with thrombotic vascular complications. We investigated the activity of the fibrinolytic system and its capacity to respond upon DDAVP stimulation in a group of 20 cyclosporine-treated patients as compared with a group of 9 azathioprine-treated patients. Furthermore, the effect of the administration of fish-oil to these patients on the endogenous fibrinolytic activity was studied in a double-blind randomized, placebo-controlled cross-over study. The cyclosporine-treated patients showed a significantly reduced plasminogen activator activity and plasmin generation response upon the infusion of DDAVP as compared with the azathioprine group. In the cyclosporine group 60% of the patients had an impaired fibrinolytic response, whereas this was found in only 11% of the azathioprine-treated patients (P < 0.05). The impairment of the endogenous fibrinolysis activity could be attributed either to a defective release of plasminogen activator from the vessel wall (67% of patients) or to high plasma levels of plasminogen activator inhibitor 1 (33% of patients). Administration of fish-oil resulted in a significant improvement of the impaired fibrinolysis in the cyclosporine group. Particularly, in patients with a defective release of plasminogen activator from the vessel wall, fish-oil treatment resulted in a normalization of the fibrinolytic activity. These results indicate that cyclosporine treatment induces an impaired fibrinolysis that may contribute to the frequent occurrence of thromboembolic complications and eventually the impairment of renal function in cyclosporine-treated patients. The beneficial effect of the administration of fish-oil on the endogenous fibrinolysis may result in a reduction of the adverse events associated with cyclosporine treatment.

Clinical and immunological follow-up of patients with severe renal disease in Wegener's granulomatosis.

Clinical and immunological data are reported of 12 patients suffering from Wegener's granulomatosis and severe renal involvement. Although 9 patients recovered from their acute illness, a long-term follow-up a relapse occurred in 4 of these 9 patients. Therefore, lifelong follow-up in this group patients seems to be mandatory. Extensive immunological investigations did not provide evidence for humoral mechanisms underlying the pathogenesis of this disease; T lymphocyte subsets in peripheral blood as well as functional reactivity of lymphocytes in vitro were also normal. However, none of the patients was able to mount a primary cellular immune response in vivo. On the other hand, kidney biopsy specimens obtained before the initiation of drug therapy revealed periglomerular and interstitial cellular infiltrations consisting predominantly of T lymphocytes with a ratio Leu 3a (OKT4)/Leu 2a (OKT8) of 5:1. This may indicate that a type IV (delayed-type) hypersensitivity reaction takes place in the kidney. These findings suggest that an abnormal cellular immunoreactivity plays a major role in the pathogenesis of Wegener's granulomatosis.