Reduction of infectious complications and costs using temporary subcutaneous implantation of PD catheters.

A limited number of authors have demonstrated that temporary subcutaneous implantation of peritoneal dialysis catheters ("Moncrief") reduces infectious complications and increases catheter life expectancy. Two operations are required to use the Moncrief catheter as compared to only one operation when peritoneal dialysis catheters are exteriorized for immediate use ("Updike"). The questions arise, then, are these findings reproducible and which catheter is the most cost-effective? In an effort to support these premises, a retrospective review of 195 patients who received peritoneal dialysis catheters from 1991 to 1995 was undertaken. Demographics, complications, life expectancy analysis, and costs were compared between Moncrief and Updike catheters. There were no significant differences between the groups, and comparisons revealed a clinically evident and statistically significant decrease in the incidence of infections with Moncrief catheters. At both one- and two-year follow-up, Moncrief catheters demonstrated a significant increase in longevity as compared to the Updike catheters. Cost comparisons between the catheter systems revealed that if patients were not undergoing immediate dialysis, placement of a Moncrief catheter was more cost-effective. Conversely, if the patient was currently undergoing dialysis, placement of an Updike catheter was more cost-effective. However, sensitivity analysis revealed that shorter exteriorization times would make the Moncrief catheter the more cost-effective choice in this patient population. In conclusion, temporary subcutaneous implantation of peritoneal dialysis catheters significantly decreases the incidence of infectious complications, increases catheter life expectancy, and is the cost-effective choice for patients who will undergo peritoneal dialysis.

The long-term effect of delayed graft function on cadaveric renal transplants treated with low-dose cyclosporine.

We evaluated the long-term effect of delayed graft function (DGF) on cadaveric renal transplant patients treated with "low-dose" cyclosporine (CsA). Between January 1985 and December 1986, 103 cadaveric renal transplants were performed. Patients were divided into 3 groups, depending upon graft function 3 days posttransplantation (PT): 1) no DGF with serum creatinine (SCr) levels less than 2 mg/dl, 2) moderate DGF with SCr of 2.0-6.9 mg/dl, and 3) severe DGF with SCr of more than 7.0 mg/dl. Overall actuarial graft survival rates for 1, 2, 3, and 4 years PT were 86, 75, 69, and 69%, respectively. Graft survival rates were the same for the 3 DGF groups at all times up to 4 years PT. Initially, renal function was best in the no DGF group, but there was no effect of DGF on renal function in any of the 3 groups 2-4 years PT. We conclude that DGF does not effect the long-term results of cadaveric renal transplants when "low-dose" CsA and prednisone are used as immunosuppressive agents.

Low-dose cyclosporine for cadaveric renal transplantation.

Low-dose cyclosporine (CsA) plus prednisone for induction and maintenance immunosuppression were used in 106 consecutive cadaveric renal transplants. Previous reports of lower initial CsA have described its use in combination with other forms of immunosuppression. An oral CsA dose of 3 mg/kg was given 2-4 hr before operation, and maintenance CsA was started 12 hr post-operatively at 1 or 1.5 mg/kg i.v. every 12 hr for non-functioning and functioning kidneys, respectively. Oral CsA was given at 3 times the i.v. dose and started 2-3 days postoperatively. The CsA dose was adjusted to maintain plasma trough levels, as measured by radio-immunoassay, of 150-200 ng/ml for the first two weeks, 125-175 ng/ml 2-4 weeks posttransplant, and 100-150 ng/ml for the second month after transplant. Between two and six months, the CsA dose was gradually reduced by 33%. Maintenance prednisone was rapidly reduced 5 mg/month to a maintenance dose of 10 mg/day. Graft survivals for low and high-risk patients at one year were 91% and 81%, respectively. Patient survivals for low-and high-risk patients at one year were 97% and 90%, respectively. Patient death was caused by: aspiration (1), suicide (1), cardiac failure (1), Mediterranean fever with colon perforation (1), and traumatic renal artery disruption (1). Except for death, grafts were lost to primary nonfunction (2), accelerated rejection at +/- 12 hr (3), medical noncompliance (1), renal artery thrombosis (1), and vascular rejection (1). Of 106 patients, 26 (25% were treated for rejection with 3.5 g of i.v. methylprednisolone over 10 days; 25/26 (96%) rejections were reversed with methylprednisolone alone. OKT-3 failed to reverse the remaining vascular rejection. All 9 conversions from CsA to azathioprine for toxicity were successful. Our definition of toxicity was rising serum creatinine, normal CsA level, and no response to 7-10 days of i.v. methylprednisolone and no change in biopsy. We were not able to distinguish CsA toxicity and rejection in most biopsies. Average serum creatinines at 1, 6, and 12 months were 1.6 mg/dl, 1.55 mg/dl and 1.65 mg/dl, respectively. We conclude that low-dose CsA plus prednisone can be successfully used for all cadaveric renal transplants without other forms of immunosuppression. Steroid-resistant rejection is extremely rare if adequate time is given for i.v. methylprednisolone treatment. Almost all "steroid-resistant rejections" were found to be CsA toxicity, and they were reversed after conversion to azathioprine.

Influenza vaccination in renal transplant recipients.

Renal transplant recipients receiving immunosuppressive therapy are prone to major pulmonary infections. Development of influenza virus infection may lead to renal allograft damage or rejection. These patients should therefore be protected against influenza viruses by vaccination. A satisfactory antibody response was found in 12 (60%) of 20 renal transplant recipients vaccinated. Among 15 control subjects, the antibody response was satisfactory in all participants (100%). Factors that might play a role in suppression of antibody response include use of immunosuppressive drugs and renal allograft function. Immunization is safe and does not appear to affect renal allograft function.

Bovine artegraft arteriovenous fistulas for hemodialysis in one-hundred patients after "conventional" arteriovenous fistulas failed.

The use of the Bovine artegraft for creation of arteriovenous fistulas in the hemodialysis patients was first carried out in the midsummer of 1971. Since that time, there has been considerable material reported in the use of this substitute as an access for hemodialysis. In this article information gained from an ongoing study of the first 100 patients in chronic hemodialysis who had Bovine artegraft arteriovenous fistulas was reviewed. The indications for operation, the standard technique, the results, the complications, and the future plans for study of the physiology and hemodynamics of this type of fistula are described. The Bovine artegraft, AV fistula can be created successfully in a high percentage of patients, offers ease of needle placement, and effective dialysis with very little complication.

Three year experience with bovine graft arteriovenous (A-V) fistulas in 100 patients.

On the basis of the preceding discussion and information, it is our conclusion that: 1. Bovine graft A-V fistuals can be created successfully in 87% of those patients who have had a failure of conventional fistuals. 2. Bovine graft A-V fistuals provide easy needle placement. 3. Bovine graft A-V fistuals give excellent access for effective hemodialysis. 4. Bovine graft A-V fistuals do not cause excessive bleeding at the puncture site. 5. Bovine graft A-V fistuals can be used immediately.