Renal Transplant Program Research Articles

End stage renal failure: 14 years' experience of dialysis and renal transplantation.

One hundred and thirteen children (59 boys and 54 girls aged from 2 to 16 years) with end stage renal failure entered the renal dialysis and transplantation programme between 1972 and 1983. They were followed up until December 1985. Ninety eight children were initially treated by haemodialysis in hospital and 15 by renal transplantation. The average wait on dialysis was seven months (range 0.1-43 months). One hundred and six children were given 129 renal transplants, 32 of which were from living related donors. At the end of 1985 94 of the 113 patients (83%) were alive, 81 (72%) with functioning grafts, 11 (10%) were receiving haemodialysis in hospital, two (1%) were being treated by continuous ambulatory peritoneal dialysis, and three had been lost to follow up. The 14 years actuarial survival was 81%. Four patients receiving dialysis and 12 who had received transplants died, a mortality of 14%. The main complications of treatment were retardation of growth in 49 (43%), hypertension in 75 (66%), and osteopathy in 36 (32%). Retardation of growth could not be reversed by successful renal transplantation. Seventy two patients (88%) assessed their health as good to excellent, and 9 (12%) as poor. Patients with a functioning graft did much better than those receiving dialysis. Treatment of end stage renal failure led to full rehabilitation in most patients, and renal transplantation was more effective than dialysis.

Cardiac abnormalities and exercise tolerance in patients receiving renal replacement therapy.

The exercise tolerance of the survivors of a consecutive group of 100 patients in a renal dialysis and transplant programme was compared with the prevalence of cardiac abnormalities detected by exercise testing, echocardiography, and radionuclide angiography. Fifty four patients attended for investigation 27 (SD 7) months after starting renal replacement therapy. Forty three of them (80%) were receiving antihypertensive treatment. Their performance on a bicycle ergometer exercise test was compared with that of 62 normal subjects and the patients divided into five groups of decreasing ability. The exercise tolerance of the patients was very poor, only 17 performing within the normal range. Impairment in exercise capacity was not explained by the type or quality of renal replacement therapy. Fourteen patients developed ischaemic electrocardiographic changes on exercise. Left ventricular ejection fraction was assessed by gated blood pool scanning in 37 patients; all nine of the patients with an abnormally low radionuclide ejection fraction also had abnormal exercise tolerance. Satisfactory M mode echocardiograms were obtained from 45 of the patients, and only two were normal. Left ventricular hypertrophy was detected in 25 (56%) of the echocardiograms, and abnormalities indicating impaired left ventricular function were common and widespread. Grouping all the abnormal cardiac features together for the patients in each exercise group showed a striking linear trend of increasing proportion of cardiac abnormalities with worsening exercise tolerance among the five exercise groups (p less than 0.001). The proportion of patients becoming unemployed within one year of starting renal replacement therapy similarly increased, from nil to 60% from the best exercise group to the most incapacitated. Twenty nine of the original cohort of 100 patients subsequently died, cardiovascular disease accounting for 12 (41%) of these deaths. Diminished exercise tolerance in patients receiving renal replacement therapy is strongly associated with cardiac abnormalities and reduced employment prospects.

Total lymphoid irradiation in the management of autoimmune diseases and organ transplantation

lmmunosuppression is generally considered an undesirable complication of irradiation in the treatment of cancer. During the past ten years, advances in our knowledge of the immune system, including the identification of subclasses of lymphocytes and definition of their functional roles, has permitted more detailed analysis of these impairments. Irradiation treatment programs directed at the lymphoid organs have been utilized in the treatment of lymphomas. Total lymphoid irradiation (TLI), which encompasses most of the body’s lymphoid tissue, is a curative therapy for many patients with Hodgkin’s disease. Although Hodgkin’s disease itself is often associated with immunological abberrations, additional marked abnormalities may be detected by in vitro tests of immunological function in patients who have been treated with TLI for Hodgkin’s disease and are alive and well for up to ten years or longer after completion of therapy. The development of animal models for TLI has permitted the initiation of studies to characterize these immunological disturbances further. More recent studies have exploited TLI as a means to immunomodulation to promote transplantation tolerance and treat autoimmune disease in man. This refresher course will review the basic laboratory studies that have been completed in rodent, canine, and primate animal models. Data from human clinical trials utilizing TLI in renal and bone marrow transplantation programs and for the treatment of autoimmune disease such as rheumatoid arthritis and lupus nephritis will also be presented.

Transplantation of kidneys from living related donors: Comparison with cadaveric kidney transplantation

In a series of 271 transplantations of renal allografts, performed over 10 years, the rates of graft survival, patient survival, and morbidity in the recipients of allografts from living related donors (47 allografts) have been compared with those in the recipients of cadaveric allografts (224 allografts). The one-year graft survival rates were 88% for allografts from living related donors (100%, if these were HLA-identical) and 55% for cadaveric allografts, while the patient survival rates were 97% and 87%, respectively, in the same period. Morbidity rates (expressed as the number of days spent in hospital) for recipients of allografts from living related donors were approximately 50% of those for recipients of cadaveric grafts. Complications in the living related donors were minimal, and acceptable. It is concluded that transplantation of allografts from living related donors has many advantages over transplantation of cadaveric kidneys, and is a valuable adjunct to a cadaveric renal transplantation programme. Greater use of living related kidney donors should be encouraged in Australia.

Renal Transplantation Program

King Faisal Specialist Hospital CommunicationRenal Transplantation Program Wajeh Y. Quinibi and MD, FACP H. Earl GinnMD Wajeh Y. Quinibi Nephrologist, Department of Medicine, Division of Nephrology, King Faisal Specialist Hospital and Research Centre Search for more papers by this author and H. Earl Ginn Nephrologist, Department of Medicine, Division of Nephrology, King Faisal Specialist Hospital and Research Centre Search for more papers by this author Published Online:1 Jan 1983https://doi.org/10.5144/0256-4947.1983.83SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionRenal dialysis was a vital breakthrough in the management of patients with end-stage renal disease. These patients' daily movements, however, are restricted by the time they must spend being dialyzed; their diets are restricted, and in short, their lives revolve around their dialysis schedules. In addition, they may suffer from substantial morbidity, some of which is related directly to the dialysis treatment.Patients fortunate enough to have successful kidney transplants often are rehabilitated to the extent that they can resume almost normal lives with less rigid or no dietary restrictions and increased freedom from the dialysis regimens. Although they feel better, these patients must take immunosuppressive medications for the remainder of their lives. Also, frequent follow-up by a physician knowledgeable about transplantation is essential.The first successful kidney transplant was done between monozygotic twins at the Peter Bent Brigham Hospital in Boston, Massachusetts, in 1954. Following this came a small number of successful transplants between identical twins before the introduction of immunosuppressive drugs such as prednisone and azathioprine. The commercial availability of these drugs in 1961 made transplant rejection easier to control, and the number of transplantations increased substantially.The development of a renal transplant program at the King Faisal Specialist Hospital and Research Centre has made it possible to accept for evaluation any patient from Saudi Arabia with documented end-stage renal disease and having a potential live, related donor. Similar patients from surrounding countries can also be evaluated but there are different financial considerations. Patients may be referred either by personal communication from a physician or through an official referral by one of the medical committees within the Kingdom. When the patient arrives for evaluation, we must evaluate the potential donors at the same time. More than one related possible donor will naturally increase the chances of finding the best histocompatibility match for the transplant candidate. The candidates are examined thoroughly, a process that takes from 6 to 8 weeks. We feel that it is necessary to instruct both donor and recipient about the risks involved in this type of surgery.Patients above 55 years of age, those with diabetes, and those with evidence of heart disease are considered high-risk patients. They are given special attention during evaluation and often more specialized testing is required before they are accepted for transplantation. Some patients may require pretransplant surgical procedures to prevent activation of a dormant infection in the native kidney by the immunosuppressive drugs required after transplantation.Although cadaver allografts are used in many transplant programs, grafts from suitable live related donors (especially from parents or siblings) are more widely preferred because the success rate is significantly higher. In our program, donors must be healthy, living relatives over 18 years of age. Second-degree relatives such as aunts, uncles, or cousins are usually unacceptable donors. Also, husbands and wives cannot donate to each other nor can unrelated volunteers. When no suitable live, related donor can be identified for a patient, the results of our evaluations are available to assist the patient's being accepted by transplant programs that have cadaver kidneys available to them.Donating a kidney must be totally voluntary. We discuss the problems and benefits with the donor and gain a feeling for his willingness to donate. This is done privately with complete confidentiality. If we feel that the donor is under family pressure to donate the organ against his will, a reason is given to exclude him as a donor.In the past, Saudi Arabian patients needing transplants had to go abroad. The King Faisal Specialist Hospital transplant team follows, at the present time, a number of these patients in the outpatient department and is willing to follow any patient who has received a kidney transplant abroad. We hope that soon all Saudi Arabian patients with end-stage renal disease who have potential live, related donors will seek transplants at this Hospital or another transplant center within the Kingdom. Previous article FiguresReferencesRelatedDetails Volume 3, Issue 1January 1983 Metrics History Published online1 January 1983 KeywordsKidney—Transplantation—Saudia ArabiaInformationCopyright © 1983, Annals of Saudi Medicine

Nosocomial aspergillosis: a retrospective review of airborne disease secondary to road construction and contaminated air conditioners.

A retrospective review of autopsy records was performed to evaluate a clustering of patients shown to have invasive pulmonary aspergillosis during the period July 1, 1978 through October 31, 1980 at Milwaukee County Medical Center, Milwaukee, Wisconsin. During this period, ten patients, all of whom were immunosuppressed by either hematologic malignancy (two), advanced age (one), or iatrogenically to prevent rejection of renal allografts (seven) were found to have invasive pulmonary aspergillosis. Prospective and retrospective evaluations of the hospital environment correlated the clustering of cases to recent road construction, and recovery of Aspergillus fumigatus and A. flavus from window air conditioners used in the renal transplantation ward suggested that some of the patients had acquired the infection nosocomially. A review of autopsy records during a seven-year period following the initiation of the renal transplant program but antedating road construction of any major consequence revealed no invasive aspergillosis among any patient autopsied.

Coccidioidomycosis in renal replacement therapy

The potential risk of coccidioidomycosis has led to concern about the advisability of maintaining renal transplantation programs in endemic areas. We reviewed the charts of 721 patients undergoing dialysis and 260 renal transplant recipients in Arizona to determine the incidence, risk factors, and clinical course of coccidioidomycosis in these immunosuppressed populations. Symptomatic infection occurred in six (0.83%) patients undergoing dialysis and 18 (6.9%) transplant recipients. Male sex and blood type B predisposed to dissemination. Urine cultures for fungus were important diagnosis aids. Four of six patients with infection limited to the thorax and five of 18 patients with dissemination remained alive after seven months to 7 1/2 years. Although the rate of dissemination (75%) and mortality (63%) from coccidioidomycosis were high, the incidence of infection was low and does not preclude renal transplantation in Arizona. Those who have received transplants elsewhere should be advised not to move or to visit areas endemic for coccidioidomycosis.

Prospective DR matching in a single center renal transplant program: [formula omitted], Univ. of Iowa and VA Medical Centers, Iowa City, IA

Prospective DR matching in a single center renal transplant program: [formula omitted], Univ. of Iowa and VA Medical Centers, Iowa City, IA

Early diagnosis of juvenile renal osteodystrophy

Renal osteodystrophy has assumed growing importance as a major and frequently disabling complication of chronic renal failure in children since the advent of successful hemodialysis and renal transplantation programs. The frequency and severity of renal osteodystrophy appears greatest in younger children with congenital diseases of the kidney and urinary tract, who experience long intervals of chronic renal failure prior to reaching end-stage. Twenty-nine children with varying degrees of chronic renal failure were studied to learn: (1) how early renal osteodystrophy can be diagnosed; and (2) how the various clinical, biochemical, and hormonal abnormalities correlate with abnormal bone histomorphometry as determined from percutaneous transilial bone biopsies. Results showed: (1) marked-to-moderate reductions in GFR (mean = 35 ml/minute/1.73 m2; range 11 to 65 ml/minute/1.73 m2); (2) elevations of serum PTH concentrations in all patients with a GFR < 45 ml/minute/1.73 m2; (3) abnormal bone histomorphometry in all patients with elevated PTH concentrations; (4) "early" renal osteodystrophy (elevated PTH concentrations and abnormal bone histomorphometry but normal serum chemistry values and radiographs) in one quarter of the patients; (5) poor correlations of serum chemistry values and radiographs with bone histomorphometry; and (6) a wide range of histologic abnormalities including predominant osteomalacia (n = 7), predominant hyperparathyroidism (n = 6), or a mixed picture (n = 11).

Psychological adaptations to a renal dialysis and transplant program: a longitudinal and cross-section investigation.

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Iliac Artery Ligation

In order to assess the effect of iliac artery ligation on the distal extremity, the ten year experience of the Johns Hopkins renal transplantation program was reviewed. Among 467 transplant procedures in 390 patients there were six cases in which the common and/or external iliac artery had been ligated for control of untoward hemorrhage from an infected arteriotomy site. These six cases were studied in detail with particular attention to ischemic sequelae in the involved leg. There were no immediate or causally-related deaths. No patient lost a leg or required an immediate reconstructive procedure for limb salvage. Four of the six recovered ambulatory status, and only two of these required a later, elective reconstruction for claudication. The combination of these six with eight other similar patients previously reported provides a total of 14 cases of iliac artery ligation in renal transplant patients. No patient suffered actual limb loss, and only three underwent subsequent elective reconstruction for claudication. It is concluded that common and/or external iliac artery ligation without immediate revascularization may be performed for control of hemorrhage with little danger of limb loss in renal transplant patients.

Psychologic and Psychosocial Aspects of Medical Practice

Excerpt In 1976Annals of Internal Medicinepublished a series of suggested readings for physicians reviewing medicine and its subspecialty fields, including neurology and dermatology, in preparation...

The Impact of 1,000 Renal Transplants at One Center

A large, comprehensive renal transplant program has a major impact not only on patient care, but also on the medical center itself and the larger community. The program at this center has advanced from 15 transplants in 1964 to 141 transplants in 1976. Fifty-nine per cent of patients transplanted have functioning kidneys at this time, including 76 children. Rehabilitation was equal to prerenal disease level in 91% of 169 recipients who lived five years with a functioning graft. Basic research in such diverse areas as renal preservation and immunology, as well as clinical research in optimum immunosuppressive therapy, resulted in significant contributions. Refinement of the mixed lymphocyte culture improved living-related graft survival at two years: 100% for HLA-identical and 91% for non-HLA-identical grafts, compared to 66% reported by the Transplant Registry for the combined group. Modification of immunosuppression improved patient survival at two years: 100% and 86% for recipients of living-related and cadaver grafts, respectively, compared to 83% and 65% reported by the Transplant Registry. The complexity of care of the patient with end-stage renal failure has required active interaction between transplant surgeons and almost every major specialty. The vast clinical material has been a great asset for training transplant surgeons, nephrologists, fellows and residents of multiple specialties, and medical students. The medical center's relationship with communities within a 250 mile radius has been strengthened, as reflected in patient referrals and the development of a multi-community-supported organ procurement system, which has allowed us to perform over 100 cadaver transplants per year for the past three years. Thus the performance of 1,000 renal transplants at this center has resulted not only in rehabilitation of many renal failure patients, but also in expanded and improved research and teaching capabilities, bringing support from multiple medical disciplines and the general community.

HYPERLIPOPROTEINAEMIA AND DIETARY FAT MODIFICATION IN HAEMODIALYSIS AND RENAL TRANSPLANT PATIENTS

A group of patients in a haemodialysis and renal transplant programme have been assessed for the frequency of lipid abnormalities. Hypercholesterolaemia was not a significant problem amongst haemodialysis patients, but mild hypercholesterolaemia was common amonst transplant patients. Mild hypertriglyceridaemia was a feature of both haemodialysis and transplant patients. Irrespective of initial lipid values, each patient was advised to undertake dietary fat modification for a period of eight months. There was a small significant lowering of plasma triglyceride values in the haemodialysis group. It is concluded that major lipid abnormalities are not a feature of this group and that the return for dietary fat modification is small, although occasional individual patients may warran hypolipidaemic therapy.

Community attitudes to renal transplantation: A statistical survey

Statistical analysis of attitudes to a new renal transplantation program was carried out in groups of medical students, nurses, house staff, faculty members, private practitioners, and ministers of religion. General acceptance of transplantation was lowest among faculty members. Nurses and students foresaw the greatest difficulties in some of the details of carrying out the program. There were no differences in opinion due to age, race, religion, or specialty. More than half of those surveyed believed that the hospital had inadequate facilities to mount an effective program.

A mathematical model of an integrated haemodialysis and renal transplantation programme.

A mathematical model of an integrated renal dialysis and transplantation programme is described. The three treatment areas—hospital dialysis, home dialysis, and transplantation—are represented in the model by three states and those states are subdivided into one and two substates respectively. Interstate transitions occur at either constant average rate or with constant average probability, depending on the relevant principal constraints. In estimating future numbers in the programme, interstate transition probabilities (or rates) may be adjusted for possible changes, such as an improvement in graft survival. Projection based on data of the early years of the Cardiff unit are compared with developments in later years. The model may be used for the calculation of future numbers in other centres or nationally by substituting the appropriate interstate transition probabilities or rates.

Effects of Hemodialysis and Renal Transplantation on Pulmonary Function

A group of patients with normal chest x-ray films accepted for a renal transplantation program underwent serial pulmonary function studies. Vital capacity and maximum ventilation decreased slightly. Parameters of abnormal pulmonary function did not change after hemodialysis. Maximum voluntary ventilation increased significantly after successful renal transplantation, which could represent an overall improvement of these patients. The impairment of the diffusing capacity for carbon monoxide was related to the anemia accompanying renal disease, and not to the azotemia itself. We conclude that in evaluating a chronic uremic patient's pulmonary status, the chest x-ray examination is most important. A group of patients with normal chest x-ray films accepted for a renal transplantation program underwent serial pulmonary function studies. Vital capacity and maximum ventilation decreased slightly. Parameters of abnormal pulmonary function did not change after hemodialysis. Maximum voluntary ventilation increased significantly after successful renal transplantation, which could represent an overall improvement of these patients. The impairment of the diffusing capacity for carbon monoxide was related to the anemia accompanying renal disease, and not to the azotemia itself. We conclude that in evaluating a chronic uremic patient's pulmonary status, the chest x-ray examination is most important.

Tertiary hyperparathyroidism occurring during a renal transplantation programme: report and discussion of three cases.

Tertiary hyperparathyroidism occurring during a renal transplantation programme: report and discussion of three cases.

Renal Transplantation: Theory and Practice

This concise yet thorough review of renal transplantation has been written by one of the most prestigious transplant groups in the world. Professor Hamburger and his colleagues at Hôpital Necker in Paris were one of the very first groups to begin renal transplantation and have maintained an active interest in both experimental aspects of transplantation immunology and clinical renal transplant programs ever since. This book is essentially split in half between experimental aspects of transplantation biology and immunology on the one hand, and clinical techniques and results of renal transplantation on the other. There is also an extensive appendix of 56 pages which outlines in greater detail the surgical and immunological techniques involved in both the clinical and experimental aspects. Each chapter has many subsections, identified in the table of contents and at the beginning of each chapter, so that the reader can quickly identify specific points of interest. An

A path to renal transplantation in Nepal

End Stage Renal Disease affects many people in the world. There are three methods of renal replacement therapy available to patients: Continuous ambulatory peritoneal dialysis, haemodialysis and transplantation. Transplantation is the most viable and cost effective form of renal replacement therapy that is available for these patients. There are 3 factors required to help ensure a successful renal transplantation program: A well legislated donor and recipient program, Human Leukocyte Antigen testing (pre and post transplant), as well as a post transplant follow up program. Keywords: Renal Transplant; South Asia; Nepal; Human Leukocyte Antigen DOI: 10.3126/jpn.v1i1.4453 Journal of Pathology of Nepal (2011) Vol.1, 52-55