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.

Ten-year experience with infant kidneys transplanted en bloc.

UNLABELLED: We analyzed the long-term outcome and function of 78 pairs of infant kidneys transplanted en bloc into adult recipients from February 1987 to February 1997. Donors were 31.2 months old (3.5-60 months), weighted 10.9 kg (5.6-20 kg), and had creatinine levels of 0.3 mg/dl (0.2-0.8 mg/dl). The kidneys had 2.6 (0-6) HLA-A, B, DR, mismatched antigens. Recipients were 36.3 years old (18-78 years), had 3.3% panel-reactive antibodies (0-71%), and weighed 71.5 kg (46-134 kg). Renal revascularization was accomplished by joining the donor aorta and vena cava to the recipient iliac artery and vein, respectively. Cold ischemia time was 23.4 h (16-53 h). Immunosuppression consisted of cyclosporine, azathioprine, steroids, and recently, mycophenolate mofetil. Rejection episodes were treated with steroids, and anti-CD3 antibodies was used in non-responders. Five en-bloc kidneys thrombosed. Two ureters developed a fistula and were repaired successfully. Five patients underwent dialysis. Death occurred in two patients with infection, six with heart attack and stroke, and one with cancer with excellent graft function. Renal artery stenosis was dilated in seven patients. Six grafts were lost to rejection (one from non-compliance at 20 months). The original disease recurred in three patients with massive proteinuria, despite excellent function. Graft survival at 42 months (1-117 months) was 79%, with serum creatinine levels at 1, 3, and 9 years of 1.2, 1.0, and 0.8 mg/ dl, respectively. Creatinine clearance averaged 88 ml/min (34-188 ml/min) and 24-h proteinuria was 146 mg (normal 10-150 mg). IN CONCLUSION: (1) en-bloc infant kidneys can be transplanted successfully with excellent long-term function into adults; (2) hyperfiltration injury was not observed; and (3) infant kidneys should be used more frequently.

En bloc transplantation of infant kidneys: ten-year experience.

BACKGROUND: Recent data have shown that en bloc infant kidneys transplanted to adult recipients functioned well. Longterm graft survival and function are not available, however. This study analyzes the 10-year experience with transplantation of en bloc infant kidneys from 1987-1997. STUDY DESIGN: This is a chart review of adult recipients of en bloc infant kidneys with respect to donors' and recipients' age, weight, creatinine, HLA antigen matching, panel reactive antibodies, cold ischemia time, surgical complications, original disease, and longterm graft function and survival. RESULTS: Five en bloc kidneys thrombosed (6.4%). Two ureteral fistulas were repaired successfully. Five patients underwent dialysis (6.4%). Two patients died of infection, six of heart attack and stroke, and one of cancer. All had excellent graft function at patients' death. Renal artery stenosis was dilated in seven patients. Six grafts were lost to rejection (one from noncompliance at 20 months). The original disease recurred in three patients with massive proteinuria despite excellent function. Graft survival at 43 months (range, 6-123 months) was 79%, with serum creatinine levels at 1, 3, 9 and 10 years of 1.2, 1.0, 0.8 and 0.8 mg/dl, respectively. Creatinine clearance averaged 88 mL/min (range, 34-188 mL) and 24-hour proteinuria was 146 mg (normal range, 10-150). CONCLUSIONS: In conclusion, en bloc infant kidneys can be transplanted successfully with excellent longterm function, hyperfiltration injury was not observed, and infant kidneys should be used more frequently.

Growth and function of en bloc infant kidney transplants: a preliminary study.

We evaluated the growth and function of 21 pairs of en bloc infant kidneys transplanted into adult recipients. Serum creatinine, 99mtechnetium-diethylenetriaminepentaacetic acid glomerular filtration rates, kidney volumes and resistive indexes were determined at 1 to 3, 3 to 6 and beyond 6 months, and compared using repeated measures analysis of variance tests. En bloc kidneys grew at a statistically significant rate (p < 0.001), for example nearly 2-fold in 3 to 6 months (209 +/- 69 cc from 132 +/- 70 cc), and approaching 3-fold at 6 months and longer (325 +/- 106 cc). Similarly, the glomerular filtration rates increased almost 4-fold (83 +/- 52 ml. from 23 +/- 11 ml. per minute) and 5-fold (121 +/- 45 ml., p < 0.001), respectively, during the same periods. Resistive indexes remained at normal range (0.60 to 0.63). Recipient blood pressure was normal. Our study shows that infant en bloc kidney transplants grow rapidly and provide excellent function to the adult recipient.

Nonreamed nailing of tibial diaphyseal fractures in blunt polytrauma patients.

The efficacy of nonreamed nailing as the treatment of choice of unstable blunt tibial diaphyseal fractures was studied. From March 1, 1990, through August 31, 1991, 72 patients with 74 fractures that required fixation were treated. One patient died and six were lost to follow-up, leaving 65 patients with 67 fractures. Follow-up averaged 21 months (range 5-43). Fisher's exact and logistic regression analyses were used to compare grades of open fractures, comminution as classified by Winquist, and dynamic and static nailings. The failure rates of 51 titanium and 16 stainless steel nails were compared. Times to union were compared by the log rank statistic method. The average time to union was 32 weeks with 26 (39%) additional operations required to achieve union; 13 dynamizations (12 successful), 12 exchange nailings (11 successful), and one plate and bone graft. The rate of reconstructive procedures to achieve union was a more sensitive indicator of difficulties achieving union than was time to union. Reoperation rates were 33% for closed or grade I and II fractures compared with 46% for grade III fractures (NS). Among closed grade I and II static versus dynamic nailing, times to union were 36 versus 25 weeks (p < 0.01), and the reoperation rates were 44% versus 13% (p < 0.04). Winquist I and II fractures required a 24% reoperation rate versus 53% for grade III and IV and segmental fractures (p < 0.01). Static locked fractures required a 48% reoperation rate versus 12% for dynamic locked fractures (p < 0.01). A logistic regression analysis demonstrated that locking mode was the most important factor in determining reoperation rates. Fifteen additional reoperations for infection, broken or painful implants, or to remodel bones that united with an incomplete circumference of cortex were performed. With an additional 12 elective nail removals, the total reoperations numbered 53 (79%). Titanium alloy nails had a 2% failure rate versus 25% for stainless steel nails (p < 0.01). Two of 28 (7%) grade III fractures became infected. All fractures united within 10 degrees of normal alignment and 1 cm of length. Nine (13%) united with an incomplete cortical circumference, refractory to dynamization and full weight bearing. Thirteen of the 58 (22%) fractures available for an evaluation of ankle motion were symptomatic, with < 10 degrees of dorsiflexion.(ABSTRACT TRUNCATED AT 400 WORDS)