The cost of steroid-free protocols in primary cadaver kidney transplantation.

Steroid-free immunosuppression regimens have been enjoying recent success in clinical transplantation. The use of antibodies required for such protocols can be an economic burden. We proposed to study their cost in our center. This retrospective study involved 147 consecutive patients subjected to 4 protocols of immunosuppression. The first received triple therapy. The second group received induction with basiliximab, whereas the third received Basiliximab plus cyclosporine (CSA) plus mycophenolate mofetil (MMF), and the fourth received Thymoglobulin plus CSA plus MMF in conjuction with only 4 days of steroid. Rejection episodes were treated with Solumedrol. Six-month charges were obtained from computerized records of the finance department, the in-house laboratories, and the transplantation service registry. All charges were expressed in 2004 dollars. Statistical analyses were obtained using chi-square, analysis of variance (ANOVA) and Kaplan-Meier tests. The 4 groups were similar with regard to donor and/or recipient gender, race, panel reactive antibodies, cold ischemia, dialysis requirements length of stay and readmission, graft survival, and function. Charges were significantly higher in the last 2 groups as compared with triple therapy.

Renal transplantation at Allegheny General Hospital with special reference to the use of extreme-age cadaveric donors.

We report our experience with 25 living-donor and 427 cadaveric-donor kidneys followed for over 6 years. Patient survival exceeds 90% at 5 years for all recipients. Overall one-year and 5-year graft survival rates were 82.7% and 65.5%, respectively. Approximately one-third of CAD were of extreme age (eg, < or = 10 and > or = 60 years old). One-year and 5-year GS rates of this group were 72.2% and 54.8%, respectively. Kidneys from elderly donors probably should be given to age-matched recipients. Infant en bloc kidneys had good GS. They also adapted well their growth and function to adult recipients and should be used more frequently to alleviate the organ shortage problem. HLA mismatches, transplant PRA level, original kidney disease, and immunosuppressive regimens significantly affected the GS. Race, sex, cytomegaloviral antibody states, unacceptable antigens, length of pretransplant dialysis, and CAD cold ischemic time had no significant effect on GS.

The incidence of gout in renal transplant recipients.

To determine the frequency of gout in our renal transplant population and to identify any predisposing factors, we retrospectively examined the outpatient records of all patients transplanted between January 1980 and July 1984 in whom the allograft functioned for at least 1 year. Two hundred forty-three charts were sufficiently complete to be evaluated. Of the 211 patients receiving corticosteroids and cyclosporine (CyA) as immunosuppression, 25 had at least one documented episode of gout (9.7% of total, 11.8% of CyA patients); no episodes occurred in the 32 patients receiving azathioprine and corticosteroid therapy (P = .05). The time from transplantation to the first episode of gout ranged from 4 months to 4 years. Of the patients without gout, 103 of the 186 receiving CyA (55.5%) and eight of 32 receiving azathioprine (25%) had asymptomatic hyperuricemia (serum uric acid greater than 8.5 mg/dL for men, greater than 7.0 mg/dL for women, P less than .01). The number of patients receiving diuretics in the CyA treated group was 142 of 211 (67%) v 12 of 32 (37.5%) in the azathioprine group. However, the increased incidence of gout or hyperuricemia in patients receiving CyA was not due to the effect of the diuretic alone. There was no correlation between the serum creatinine and uric acid in either the CyA or azathioprine group (r value for CyA group = -.06 and for the azathioprine group = -.26). Compared with patients receiving azathioprine, we conclude that there is an increased incidence of gout and/or hyperuricemia in renal transplant patients treated with CyA.(ABSTRACT TRUNCATED AT 250 WORDS)

Transmission of infection with herpes simplex virus by renal transplantation.

Disseminated infection with herpes simplex virus type 2 was identified in two patients 20 days after they had received kidney transplants from the same organ donor. Neither patient had neutralizing antibody to herpes simplex virus before transplantation, and both had herpes simplex virus isolated from surveillance cultures of urine before the onset of clinical symptoms. A clear focus of primary infection was not found in either patient. Analysis of the patients' isolates by DNA restriction endonuclease analysis strongly suggested that the strains were identical. These data implicate the allografts as the source of the viral infection.

Evaluation of cardiovascular risk for renal transplantation in diabetic patients.

Cardiovascular disease contributes in a major way to morbidity and mortality in diabetic patients with end-stage renal disease. Sixty patients with type I diabetes were evaluated prior to renal transplantation to determine the risk of cardiovascular complications. On the basis of results of thallium stress testing and/or cardiac catheterization, each patient was assigned to one of five categories. There were no cardiovascular events in the seven patients who had negative results on stress testing. Of the remaining 53 patients, all of whom underwent cardiac catheterization, 30 had normal coronary arteries. None of these 30 patients had any cardiac morbidity, and the two deaths that occurred in this group were not attributable to cardiac causes. Significant coronary artery disease was present in 38 percent of the patients. The overall mortality rate was 5.4 percent in those patients without coronary artery disease and 43.5 percent in those with the disease. In addition, the mortality rate in patients with coronary disease classified as severe was 62 percent, whereas it was 20 percent in those categorized as having moderate disease. The data indicate that patients with diabetes and end-stage renal disease who are at highest risk for cardiovascular events can be identified, and these patients probably should not undergo renal transplantation.

Acute respiratory failure due to Pneumocystis carinii pneumonia: clinical, radiographic, and pathologic course.

The clinical, radiographic, and pathologic correlates of acute respiratory failure due to Pneumocystis carinii pneumonia were studied in 12 renal transplant patients treated with cyclosporin (CS) and prednisone. Six patients required only supplemental oxygen, while the other six patients developed the adult respiratory distress syndrome (ARDS) requiring prolonged mechanical ventilation despite similar predisposing factors and prompt initiation of therapy. Ten (83%) patients survived. Increased frequency of human leukocyte antigen (HLA) DR6 was noted in six of the 11 patients tested. The resolution of radiographic infiltrates was significantly slower in ARDS patients; however, there was no apparent difference in the severity of early alveolar damage between the two groups. There was also no association between the development of ARDS due to P. carinii pneumonia and the mean daily dose of CS and prednisone, the presence of cytomegalovirus infection or pneumonia, HLA-DR6 antigen, or initial hypoxemia.

Fluorometric determination of DNA in cartilage of various species.

A sensitive, modified 3,5-diaminobenzoic acid (DABA), fluorometric DNA assay was developed and compared to mithramycin and ethidium bromide assays in determining the DNA content of dense connective tissues including: Swarm rat chondrosarcoma, rabbit, dog, monkey, and most importantly, adult human articular cartilage. In the more cellular cartilages, the three methods gave equivalent results. However, in the relatively acellular human cartilage, the DABA method was shown to be superior. Both the mithramycin and ethidium bromide gave falsely high values compared to the DABA method, which by subtraction after DNase digestion approached the DABA value. The latter was completely DNase sensitive. With the DABA method, the DNA content of human cartilage can be obtained on less than 5 mg wet weight of fresh, alcohol-fixed, or lyophilized material. While the DNA can also be released by digestion with papain or protease from Streptomyces griseus, proteinase K was preferable. The comparison of literature values for other fluorometric and spectrophotometric assays of human cartilage suggest these methods overestimate human articular cartilage DNA concentrations, whereas the DABA values were in line with those predicted from previous morphometric analysis. Thus, the modified method represents an improvement in DNA analysis of dense connective tissues.