Delayed complications of renal transplantation and their prevention.

The complications of cadaveric renal transplantation in a group of 10-year survivors are presented. Fifty-two (44%) of 119 graft recipients survived more than 10 years, 48 with their original allograft. The major causes of death in the others were bacterial (24%) and other (10%) infections, cerebral (12%) and myocardial (7.5%) vascular disease. Serious morbidity in the survivors included infectious episodes (55%), skin cancer (40%), vascular disease (30%), cataracts (45%) and aseptic necrosis of bone (13%). Only six (12%) patients had no complications. Although complications were frequent, 34 patients (72%) were fully rehabilitated to work or household duties. Several recipients have become parents. Prevention of the late complications of transplantation must be aimed at reducing the known risk factors early in the course of renal failure. These include hypertension, obesity, cigarette smoking and sun exposure.

Long-term survival after cadaveric renal transplantation.

In a series of 404 consecutive first cadaver kidney transplants performed since 1967 the actuarial five- and 10-year survival of patients were 61% and 47% respectively and of grafts 46% and 36%. In more than four-fifths of the patients surviving these intervals the original cadaveric grafts were functioning at these times, and most of the remainder were sustained by subsequent grafts. Although graft survival has remained static since 1967, patient survival improved. Results for 43 consecutive second cadaver transplants were similar after five years to those of first grafts. These results promote the acceptability of cadaveric transplantation as a long-term treatment for chronic renal failure.

Control of bleeding after renal biopsy with epsilon-amino-caproic acid.

EACA proved useful in controlling severe bleeding after renal biopsy. In 6 patients who required transfusion for prolonged or severe bleeding, haemorrhage ceased and no further transfusions were necessary after EACA therapy. No serious side-effects were encountered.

Analgesic abuse, renal parenchymal disease and carcinoma of the kidney or ureter.

In a consecutive series of 88 cases of carcinoma of the kidney and upper urinary tract seen at one hospital, 31 had malignant urothelial tumours of the renal pelvis or ureter. Forty-two per cent of these transitional-cell carcinomas occurred in patients with renal papillary necrosis following upon prolonged and heavy analgesic ingestion. Other possible aetiological factors were heavy cigarette smoking (61% of cases), long standing urinary obstruction or infection (23%) and possible occupational exposure (6%); in only four cases (13%) was there no identifiable aetiological factor. Those cases with analgesic nephropathy were characterised by renal functional impairment, hypertension and interstitial nephritis, but there was no difference in the clinical behaviour or pathological appearances of the tumours in the two groups. The clinical and experimental evidence that certain metabolites of phenacetin are carcinogenic is reviewed.

Renal transplantation. Effect on the ischemic heart disease of essential malignant hypertension.

In 14 of 204 consecutive cadaveric renal allograft recipients, the primary diagnosis was essential hypertension. Four patients had manifest ischemic heart disease before transplantation. Three of these patients died within 31 months of transplantation from recurrent myocardial infarction, and the fourth experienced coronary insufficiency. Cadaveric renal transplantation does not prevent the progression of coronary artery disease in patients whose renal failure was due to essential hypertension. In the presence of angina or previous myocardial infarction, these patiemts may be better treated by maintenance hemodialysis.

A controlled clinical trial of machine perfusion of cadaveric donor renal allografts.

Outcome in eighty-eight recipients of cadaveric donor renal allografts preserved before implantation by machine perfusion with a solution of human albumin was compared to that for eighty-three recipients of similar kidneys implanted after simple cold storage. Average total ischaemic intervals for machine-perfused and cold-stored kidneys were 18 and 4 1/4 hours, respectively. Machine-perfused kidneys were implanted regardless of perfusion characteristics. Initial function and 1-month and 1-year graft survivals for the machine-perfused group (58%, 85%, 68%, respectively) were either similar or improved compared to those of cold-stored kidneys (58%, 81%, 52%, respectively). Improved 1-year survival for machine-perfused grafts was dependent upon reduced rejection. Careful donor selection and management ensured good machine perfusion of kidneys on 90% of occasions. In the other 10%, despite poor perfusion characteristics, outcome for kidneys was similar to those with good perfusion characteristics. Antilymphocyte globulin treatment reduced rejection whether allografts were machine perfused or not. In the absence of antilymphocyte globulin treatment, machine-perfused kidneys did much better than cold-stored kidneys. Machine perfusion had important advantages and improved the results in kidney-graft recipients.

Plasma renin concentration in hypertension produced by unilateral renal artery constriction in the rat.

1. Plasma renin concentration (PRC) and blood pressure were studied sequentially, 24 h to 42 days post-operatively, in rats subjected to unilateral renal artery constriction without contralateral nephrectomy. 2. The PRC of rats failing to develop hypertension remained normal, whereas the mean PRC of twenty-two rats that became hypertensive was five times normal on day 14 of the study when the hypertension was becoming established. 3. In eleven of the twenty-two rats that became hypertensive, PRC did not exceed the upper limit of normal. In the remaining hypertensive rats, the increase in PRC was not always temporally related to the increase in blood pressure. A significant correlation between PRC and blood pressure did not emerge until day 35 of the study. 4. Despite these anomalies, linear regression analysis of 169 pairs of PRC and blood pressure measurements during the 42 day period of development of hypertension in twenty-two rats revealed a highly significant correlation between log PRC and blood pressure (P smaller than 0.001). 5. It is concluded that factors other than the plasma concentration of renin are involved in the early stages of development of hypertension induced by renal artery constriction. Nevertheless, PRC and blood pressure are intricately related.

Diseases causing end-stage renal failure in New South Wales.

The nature of the original renal disease was determined in 403 consecutive cases of end-stage renal failure, in 317 of which the clinical diagnosis was corroborated by histological examination of the kidney. Five diseases accounted for 20 or more cases--glomerulonephritis (31% of the total), analgesic nephropathy (29%), primary vesicoureteral reflux (8%), essential hypertension (6%), and polycystic kidneys (5%). In only four cases did renal failure result from chronic pyelonephritis without a demonstrable primary cause. Greater use of micturating cystography and cystoscopy and routine urine testing for salicylate are advocated for earlier diagnosis of the major causes of "pyelonephritis". The incidence of end-stage renal failure in people aged 15-55 in New South Wales was estimated to be at least 34 new cases per million of total population each year.

Renal hypertension in rats immunized against angiotensin I and angiotensin II.

Rats, actively immunized against angiotensin I (AI) and angiotensin II (AII), were subjected to unilateral renal artery constriction to determine whether the resulting hypertension, which may still ensue in the animal immunized against AII, could be prevented by such combined immunity. Sustained immunity to both AI and AII neither changed preoperative blood pressures of the rats from those of control mock-immunized rats nor altered the incidence or severity of renal dip hypertension. Vascular hyperresponsiveness to small quantities of free angiotensin could not be invoked to explain the hypertension, for there was no significant difference between mock-immunized hypertensive animals, and those remaining normotensive, regarding pressor sensitivity to intravenous AI, AII, renin, and norepinephrine. (AI + AII)-immunized hypertensive rats required AI doses averaging 260 times greater than nonimmune hypertensives to elicit equipressor responses, and were refractory to renin, but not to norepinephrine. Thus, while previous studies have not excluded direct participation of endogenous AI in renal clip hypertension in rats, evidence from our experiments makes it extremely difficult to sustain any pressor function therein for circulating AI or AII. Our results also preclude involvement of AII produced from circulating AI by conversion within arteriolar walls, close to receptor sites, since AI immunity would block this mechanism of action.

Factors influencing the incidence of postoperative abdominal adhesions: an experimental study.

PIP: Adult male Wistar rats were anesthetized with intraperitoneal sodium pentobarbitone, and laparotomies were performed to determine the role of common surgical practices in the etiology of intestinal adhesions. Rats were divided into 4 groups (Group 1, control; Group 2, small intestine delivered from the abdomen and placed on the skin without protection; Group 3, small intestine kept moist by covering with saline-soaked gauze; and Group 4, small intestine placed in plastic bag). At the end of 1 hour, all intestine were replaced in the peritoneal cavity, and rats were sacrificed 1 week later and examined for peritoneal adhesion formaiton. In general, the incidence of fibrinous adhesions was increased by removing the intestines from the peritoneal cavity. Groups 3 and 4 showed no lessening of adhesion formation with their various treatments. Incidence of plastic adhesions in laparotomy wounds closed without suturing was lower than when sutures were used. No difference was noted among types of suture material. The phenomenon of suture-induced adhestions seems a result of a reduction of fibrinolysin activity of serosa cells at the site, and the presence of the suture material allows the adhesion a harbor to establish itself in.^ieng