Single pediatric donor kidneys for adult recipients: the San Antonio experience.

Early, sustained and significant growth occurs in single kidneys from donors < or = 4 years of age transplanted into adult recipients who are receiving CsA therapy. Early and late renal function of single kidneys from donors < or = 4 years of age transplanted into adult recipients is more than adequate. Allograft loss from surgical complications (5%) is not excessive. Allografts from donors < or = 4 years of age are very vulnerable to early rejection. Allograft survival of single kidneys from donors < or = 4 years of age is equal to that reported for cadaveric kidneys from donors > 50 years of age. Single kidneys from donors < or = 5 years of age have an allograft survival equal to that for kidneys from donors of the same age that are transplanted en-bloc. One-year allograft survival among recipients of kidneys from donors < or = 4 years of age receiving 14 days of induction therapy and aggressive treatment of rejection (75%) approaches that of the ideal donor (83%). Kidneys from donors < or = 4 years of age represent an underutilized resource.

Successful transplantation of 50 single unit pediatric kidneys ages 11 to 48 months into adult recipients.

There is currently an imbalance between the need for cadaveric kidneys for transplantation and the supply. The medical criteria for accepting cadaveric donors are changing and organs that were originally thought to be unacceptable have functioned well. Previous reports have discussed the problems with transplanting pediatric allografts less than 4 years old into adult recipients, and the results have not been encouraging. From 1986 to 1991 a total of 50 kidneys ages 11 to 48 months were transplanted as single units into adult recipients (Group A). Ninety-one adult donor cadaveric transplants were used as controls (Group B). The cadaveric transplants were 2nd or 3rd transplants in 7 of the Group A and 12 of the Group B patients. Renal preservation, storage times, and demographics were the same. Prednisone, cyclosporine, and either Minnesota ALG or OKT3 were used for immunosuppression in both groups. Imuran was added in immunologically high-risk patients. The 1-year actuarial patient and allograft survivals for Group A versus Group B were 89.5% versus 94.2% (p=0.49) and 71.3% versus 87.8% (p=0.01), respectively. There was no difference in allograft or patient survival in kidneys from donors 11-24 months of age or 25-48 months (p=0.56). Renal growth, as measured by sonography, occurred while on cyclosporine A. Excretory and hormonal function as measured by creatinine and hematocrit both improved. Seventy percent of the Group A patients and 76% of the Group B patients were free from rejection in the first 2 months post transplantation (p=0.45).(ABSTRACT TRUNCATED AT 250 WORDS)

Renal transplantation into ileal conduits: results and long-term follow-up.

From 1977 through 1990, 708 renal transplants were performed at our institution. Eight of these allografts (1.1%) were placed into recipients who required ileal conduits. This report describes the long-term follow-up of these patients. Five out of 8 patients currently have functioning allografts 29 to 102 months after transplantation (with a mean allograft survival of 50 months). Construction of an ileal conduit in patients without bladders or in those who have non-functioning bladders is a straightforward approach with minimal increased morbidity and good long-term results.

Evaluation of pediatric cadaver kidneys transplanted into adult recipients receiving cyclosporine.

The major problem in clinical transplantation is the imbalance between the need for cadaveric organs and the available numbers of donors. If pediatric kidneys were transplanted into adult recipients when no pediatric recipient was available, the potential number of renal donors would be increased by 15 to 20%. Some centers are reluctant to use pediatric kidneys for adult recipients because of recent reports indicating poorer patient and allograft survival, increased delayed graft function, increased post-transplant hypertension and increased technical complication. (There also has been concern that the nephrotoxic effect of cyclosporine A would retard the organ growth that is necessary to provide normal renal function in adults.) A retrospective analysis was performed on 18 adult recipients who received kidneys from cadaver donors 14 months to 12 years old (group 1). These patients were compared to 106 adult recipients who received kidneys from donors greater than 12 years old (group 2). Actuarial patient survival at 1 year was 85% for group 1 and 95.8% for group 2 (p equals 0.13), while 1-year actuarial allograft survival was 83.1% for group 1 and 81.1% for group 2 (p equals 0.87). There was no significant difference between groups 1 and 2 in the frequency of delayed graft function, serum creatinine at 1, 3 and 6 months after transplantation, incidence of post-transplant hypertension or frequency of surgical complications. It is of interest that the pediatric kidneys had significant growth during the initial post-transplant month. Sonographic examination at postoperative days 1 and 30 demonstrated a mean increase in size from 80.7 to 143.5 cm. (p less than 0.001). In this series pediatric kidneys were safe and effective donor organs in adult recipients, and increased the available number of organs by 15%.

Conventional immunosuppression after deliberate third party transfusions versus cyclosporine in living related renal transplant recipients.

A total of 93 recipients of either HLA-identical (34) or 1-haplotype matched (59) living related donor renal transplants was assigned prospectively into immunosuppressive treatment groups on the basis of transfusion histories obtained at the initial evaluation for transplantation. Patients who received 0 to 2 third party transfusions were given no further transfusion, and received cyclosporine and prednisone immunosuppression after transplantation (cyclosporine group). Patients who received 3 or 4 third party transfusions were given additional transfusions until 5 had been received, and were managed with azathioprine and prednisone after transplantation (azathioprine group). Patients who already received 5 or more third party transfusions had no additional transfusions and were assigned to the azathioprine group. No patient had a positive crossmatch to the potential donor after initial evaluation and confirmation of a negative crossmatch. The number of rejection episodes per patient after transplantation was significantly higher in the azathioprine group for HLA-identical (p equals 0.001) and 1-haplotype (p equals 0.003) recipients. One-year patient survival rats for the HLA-identical cyclosporine and azathioprine groups were 100 and 94 per cent, respectively, with respective 1-year allograft survivals of 100 and 89 per cent in the 2 groups. In the 1-haplotype group 1-year patient survival rates were 95 and 94 per cent for the cyclosporine and azathioprine groups, respectively; allograft survival was 81 per cent for the cyclosporine group and 91 per cent for the azathioprine group. None of the observed differences in graft or patient survival between the 2 groups was statistically significant. Deliberate third party transfusions with conventional immunosuppression and cyclosporine immunosuppression are effective methods to treat recipients of living related donor renal transplants.

Upper gastrointestinal bleeding following renal transplantation.

Upper gastrointestinal bleeding has been shown to be a common complication of renal transplantation and one which carries a significant risk of mortality. In a retrospective review of 200 consecutive renal transplants in 194 patients, we found an incidence of only 6 per cent and a mortality rate of 8.3 per cent. Allograft survival in this group of patients was 58 per cent. These results are the product of careful preoperative evaluation, close attention to the patients for early signs of bleeding, and aggressive diagnostic and therapeutic intervention at the first evidence of bleeding. We also report an association of hypercalcemia with post-transplant upper gastrointestinal bleeding, with cessation of bleeding after parathyroidectomy.

Hypercalcemia-induced upper gastrointestinal bleeding after renal transplantation.

Hypercalcemia is common in patients after renal transplantation and may stimulate gastrin hypersecretion with associated peptic disease. We report on 2 patients with hypercalcemia and life-threatening gastrointestinal hemorrhage controlled by subtotal parathyroidectomy. Retrospective review of our last 10 patients with gastrointestinal hemorrhage revealed that all of those with normal renal function had elevated serum calcium levels. Because of the increased mortality associated with gastrointestinal hemorrhage in renal transplant patients (43%), patients prone to development of hypercalcemia may benefit from early subtotal parathyroidectomy.

Basic microvascular techniques and principles.

This article will discuss the advantages and disadvantages of the various types of optical magnification currently available. The instruments necessary for performing most operations will also be presented. Attention will be focused on the physical properties and technical considerations of microvascular anastomosis. The principles and techniques employed for joining small blood vessels are almost always valid and transferable to reconstructive surgery of other small tubes such as the ureter, bowel, etc.

Survival of cadaveric renal allografts in Hispanic as compared with Caucasian recipients.

Evaluation of allograft survival rates revealed a significantly better overall graft survival in Hispanic (n = 66) as compared with Caucasian (n = 38) recipients of primary cadaveric renal transplants. There were no significant differences between the Hispanic and Caucasian cadaveric recipient groups in terms of patient survival, pretransplant transfusion status, immunosuppressive protocols, rejection therapy, mean age, or frequency of diabetes mellitus. Cadaveric donor ethnic origin (i.e., Caucasian or Hispanic) did not significantly alter graft survival rates in either recipient ethnic group. Although Caucasian patients with splenectomies had better cadaveric graft survival than Caucasian graft recipients without splenectomies (P = .02), splenectomy had no significant effect on the renal allograft survival rate in Hispanics. Other factors that were evaluated and found not to correlate significantly with cadaveric graft survival rates were donor recipient HLA matching (A, B, or DR), and panel reactivities of recipient pregraft serum samples. In contrast to the superior cadaveric renal allograft survival in Hispanic as compared with Caucasian recipients, 1-haplotype-matched or 2-haplotype-matched living-related renal allografts had comparable graft survival rates in Caucasian and Hispanic recipients. These results indicate that Hispanics without splenectomy enjoy a cadaveric renal allograft survival rate superior to nonsegregated populations (treated with conventional immunosuppression) reported elsewhere.

Plasmapheresis--adjunctive treatment for steroid-resistant rejection in renal transplantation.

Plasmapheresis was used to treat steroid-resistant rejection in 32 of 154 patients (21.1 per cent) receiving renal allografts during a 3 1/2-year interval. The 2-year actuarial patient and allograft survival rates for the 32 patients were 93.3 plus or minus 5 and 56.9 plus or minus 9 per cent, respectively. Mean patient followup was 18.8 months. No immunologic rebound was noted in any of the 19 patients who responded initially to plasma exchange. Although 14 of these 19 patients had peak creatinine levels of 4 to 14.5 mg. per cent during the rejection reactions significant and sustained improvement in renal function was noted. This was not a controlled trial but the results are sufficiently encouraging to warrant continued evaluation of plasmapheresis as a therapeutic adjuvant in the treatment of humoral or steroid-resistant rejection.

Effect of pretransplant blood transfusions and splenectomy on renal allograft survival in the Lewis rat.

Both pretransplant blood transfusions and pretransplant splenectomy have been shown to improve renal allograft survival in humans and experimental animals. A study was undertaken using the Lewis rat to determine if any combination of pretransplant splenectomy and pretransplant blood transfusions exerted either a synergistic or deleterious effect on renal allograft survival. Pretransplant splenectomy and pretransplant blood transfusions used singly significantly prolonged renal allograft survival. Pretransplant splenectomy followed by 3 blood transfusions also significantly prolonged renal allograft survival. This finding implies that secondary sites of suppressor cell activity, for instance lymph nodes, can be stimulated by blood transfusion and produce prolonged allograft survival in the absence of the spleen. No combination of pretransplant blood transfusion and splenectomy was synergistic. In fact, the group that had pretransplant transfusions followed by splenectomy had allograft survival no different from the control group.