Long-term results of 1047 cadaveric kidney transplantations with special emphasis on initial graft function and rejection.

We studied the effect of initial graft function and acute rejection on graft survival in 1047 cadaveric renal transplantations during 1991-1997 with a constant policy of donor selection, graft allocation, and immunosuppression. The overall 1- and 5-year patient survival rates were 96 % and 88 %, and the 1- and 5-year graft survival (GS) rates were 92 % and 78 %. Delayed graft function (DGF) occurred in 31 % and there were 1.2 % never-functioning grafts. One-year GS in transplantations with early graft function (EGF) was 95 % compared to 87 % in DGF (P < 0.001). Donor age and cause of death, type of graft perfusion and cold ischemia time, and type and length of dialysis treatment were significant factors in determining the onset of graft function. These factors did not have a significant direct effect on GS. Early ( < 100 days) acute rejection occurred in 25 %. In transplantations without rejection, the 1 and 5-year GS was 93.3 % and 80.8 %. In acute rejection responding to steroids, the GS was equal to that up to 3 years, but after that a significantly worse survival rate was observed (1- and 5-year GS: 93.6 % and 73.4 %). DGF was detrimental to GS both in transplantations without rejection and in all rejection types.

Peritoneal dialysis access: prospective randomized comparison of the Swan neck and Tenckhoff catheters.

OBJECTIVE: To examine the impact of peritoneal catheter configuration on mechanical complications, catheter survival, probability of episodes of peritonitis, and probability of exit-site infections associated with the use of catheters for continuous ambulatory peritoneal dialysis (CAPD). DESIGN: Prospective randomized trial. SETTING: CAPD unit in one university hospital, serving a population of 1.2 million. PATIENTS: Forty consecutive patients requiring their first dialysis catheter for future CAPD were randomized to receive either a two-cuff permanently bent Swan neck catheter or a two-cuff straight Tenckhoff catheter. The skin exit was downward-directed in the Swan neck group and upward-directed in the Tenckhoff group. RESULTS: Dialysate leak, catheter migration, or tunnel infection did not occur in any of the patients. Three outer cuff extrusions needing cuff shaving occurred, all in the Tenckhoff group (p = 0.1). No significant differences could be demonstrated in catheter survival at 2 years, probability of episodes of peritonitis, or probability of exit-site infections. CONCLUSION: Catheter configuration did not influence the catheter-related mechanical or infectious complications, and equally good results were obtained with both catheter types studied.

Surgical implantation of CAPD catheters: presentation of midline incision-lateral placement method and a review of 110 procedures.

One hundred-and-ten consecutive surgically implanted one-cuff straight peritoneal dialysis catheters in 103 adult patients over a 7 year period have been reviewed. All catheters were placed for chronic dialysis (CAPD). There were no early failures. Early complications consisted of one leak, 14 migrations, and two wound infections. In the long term 15 patients required transfer to haemodialysis (5 recurrent peritonitis, 7 unable to cope, 3 inadequacy of dialysis). Overall probability of catheter survival was 92.4% at 1 year and 82.4% at 2 years. The surgical implantation technique described provides a safe, reliable access for peritoneal dialysis with a low complication rate.

Catheter configuration and outcome in patients on continuous ambulatory peritoneal dialysis: a prospective comparison of two catheters.

OBJECTIVE: To examine the impact of peritoneal catheter configuration on mechanical complications, catheter survival, probability of episodes of peritonitis, and probability of exit-site infections associated with the use of catheters for continuous ambulatory peritoneal dialysis (CAPD). DESIGN: Prospective randomized trial. SETTING: CAPD unit in one university hospital. PATIENTS: Forty consecutive patients requiring a dialysis catheter for future CAPD were randomized to receive either a single-cuff straight Tenckhoff catheter or a permanently bent single-cuff Swan neck catheter. The skin exit was upward-directed in the Tenckhoff group and downward-directed in the Swan neck group. RESULTS: Dialysate leak occurred in one patient and symptomatic catheter tip migration in 3 patients with the Tenckhoff catheter but in none with the single-cuff Swan neck catheter (p = 0.5, p = 0.12). No significant differences in catheter survival at 2 years, probability of episodes of peritonitis, or probability of exit-site infections could be demonstrated. CONCLUSION: Catheter configuration did not influence the catheter-related mechanical or infectious complications. We were unable to demonstrate any advantage of the newer, permanently bent single-cuff Swan neck catheter over the conventional straight type.

Long-term consequences of different immunosuppressive regimens for renal allografts.

The long-term effects of four different immunosuppressive regimens on renal allografts have been investigated up to four years. A total of 128 recipients of first cadaveric renal allograft were randomized, after an initial induction period, to receive either triple drug therapy--i.e., (low-dose) cyclosporine, azathioprine, and methylprednisolone, or any possible combination of two drugs--i.e., Aza plus CsA, Aza plus MP, and CsA plus MP. The actual four-year graft survival rates for the triple therapy, Aza plus CsA, Aza plus MP, and CsA plus MP groups were 72%, 69%, 75%, and 59%, and patient survival rates were 78%, 81%, 81%, and 84%, respectively, with no significant differences. The cumulative number of chronic rejections up to 4 years was 0.09, 0.29, 0.25, and 0.34 per patient per group (P = ns), respectively. At 2, 3, and 4 years posttransplantation, the graft function was significantly worse in the Aza plus MP group compared with the triple therapy group (P < .05). Of the 98 patients who did not have type I or II diabetes at the time of transplantation, 17 developed posttransplantation diabetes mellitus or an abnormal glucose tolerance test within 2 years posttransplantation. All these patients had received steroids and none of the patients without steroids had these abnormalities. At two years the mean cholesterol level was highest in the Aza plus MP group, 6.8 mmol/L and lowest in the group receiving triple therapy, 5.8 mmol/L (P = ns). The use of (low-dose) CsA was not associated with lipid abnormalities or with disturbances in glucose metabolism. A protocol graft biopsy was performed at two years on all functioning kidneys, and the histological changes were scored blindly. No CsA-specific changes, except isometric vacuolation in tubuli, were found. Histological alterations characteristic of chronic rejection were expressed as "chronic allograft damage index." Chronic allograft damage index was lowest in the triple therapy group, 1.5, compared with the other groups, 3.2-4.3 (P = .01), indicating the least histopathological change in the triple therapy group. In conclusion, this long-term study did not show any serious cyclosporine-related side-effects when used in low dose in combination with two other drugs. Some side-effects, such as posttransplant diabetes mellitus and probably some lipid abnormalities, could rather be traced to a higher dose of steroids. Moreover, the triple drug therapy was more efficacious than any double drug regimen in the prevention of chronic histological changes in renal allografts.

Acute vascular rejection in renal transplantation--diagnosis and outcome.

Thirty episodes of histologically verified acute vascular rejection in kidney transplant recipients were studied. In 11 grafts the rejection was mainly vascular, whereas in 19 grafts a concomitant cellular rejection was seen. Histological features prognostic for bad outcome were glomerular necrosis and thrombi in the arteries and arterioles. Characteristic findings in transplant cytology, i.e., high number of monocytes and low number of lymphocytes and blast cells were noted prior to the onset of clinical signs of rejection, and this finding was also persisting throughout the rejection episode. The numbers of lymphocytes and blast cells were significantly lower in grafts with a pure vascular rejection than in grafts with a concomitant cellular rejection. Vascular rejection was reversible in 15 cases. As rescue therapy plasmapheresis and added immunosuppression were often successful.