Hydronephrosis in a pregnant renal transplant patient.

Although pregnancy can cause hydronephrosis in native kidneys, renal transplant dysfunction during pregnancy due to obstruction is rare. A 22-week pregnant renal transplant patient presented with deteriorating renal function (serum creatinine 5.22 mg/dL from 2.07 mg/dL 3 weeks previously). Ultrasound showed transplant hydronephrosis with the graft compressed between the gravid uterus and liver. Percutaneous nephrostomy was placed with improvement in graft function. The nephrostomy remained in situ for the rest of the pregnancy. The nephrostomy was removed postpartum with no recurrence of hydronephrosis and subsequent transplant biopsy showed no evidence of rejection. The gravid uterus may obstruct a transplanted kidney.

Biocompatible membranes do not promote graft recovery following cadaveric renal transplantation.

BACKGROUND: Controversy surrounds the role of biocompatible membrane dialyzers in treatment of acute renal failure. Studies that have shown a benefit have involved critically ill patients where renal recovery and patient mortality are influenced by other comorbid disease. The aim of the present work is to clarify this issue in a more homogeneous population of patients with acute renal failure following cadaveric renal transplantation. METHODS: All patients with delayed graft function between January 1996 and February 1998 were randomized to receive either a biocompatible (BCM, polysulfone) membrane or bioincompatible (BICM, cuprophane) membrane for dialysis until onset of graft function. RESULTS: Forty-one patients were randomized, 23 to receive BCM and 18 BICM. Five patients (2 BCM, 3 BICM; p = NS) with primary non-function of graft were excluded from analysis, leaving 36 cases of acute tubular necrosis (ATN). Patient and donor characteristics were similar in both groups. The BCM group had significantly longer periods of dialysis dependency compared to the BICM group (14 vs 10 days; p = 0.03). There was a tendency towards higher serum creatinine levels in the short term in the BCM group (318 vs 164 micromol/l at 1 month (p = 0.1), 190 vs 169 micromol/l at latest visit (p = 0.07)) and a greater number of acute rejection episodes in the BCM group (3.7 vs 1.7 episodes per 100 days of dialysis dependency, p = 0.1). With an intention-to-treat analysis of all 41 patients originally randomized, there was no significant difference in time to graft recovery between the 2 groups (p = 0.18). CONCLUSIONS: In the setting of ARF posttransplantation, we have found no evidence to support the use of biocompatible membranes for dialysis. Rather, our study provides argument against a large benefit for the use of BCM in the recovery of ARF, as suggested by earlier studies.

Early graft function and patient survival following cadaveric renal transplantation.

BACKGROUND: The influence of events that occur early following renal transplantation such as delayed graft function (DGF) and acute rejection on long-term graft survival has been widely reported, but its association with patient survival has received less attention. METHODS: We studied 589 patients who received their first cadaveric transplants between 1984 and 1993, all of whom received cyclosporine-based immunosuppression and who had a median follow-up of seven years. The following factors were identified, and both univariate and multivariate analyses were used to determine their association with long-term patient and graft survival: age, sex, duration of pretransplant dialysis, primary renal disease, immediate graft function (IGF), DGF, primary nonfunction (PNF), acute rejection, and serum creatinine at 3, 6, and 12 months. RESULTS: Patients with PNF had a poorer survival than those with DGF and IGF (P = 0.01), but there was no difference in survival between DGF and IGF (P = 0.54). Good graft function (serum creatinine of less than 200 mumol/liter) at three months was predictive of better long-term patient survival (P = 0.03). Other factors associated with poor patient outcome were older age, diabetes, adult polycystic kidney disease, male gender, and acute rejection. Cardiovascular disease was the most common cause of death (51.8%). Good graft function at three months (P < 0.001) and an absence of rejection episodes (P = 0.01) were associated with better graft survival. CONCLUSION: Patients with poor levels of early graft function (but not DGF) and those with either acute rejection episodes or early graft loss are at an increased risk of early death. These high-risk groups should be targeted for interventional studies in an attempt to improve patient survival.

Long-term outcome of a prospective randomized trial of conversion from cyclosporine to azathioprine treatment one year after renal transplantation.

BACKGROUND: Since the introduction of cyclosporine (CsA), 1-year renal allograft survival has improved, but concern persists about the long-term adverse effects of CsA, especially with respect to renal function and blood pressure. This randomized controlled trial was set up to establish whether withdrawal of CsA would alter long-term outcome. METHODS: Adult patients who, at 1 year after renal transplantation, had a stable serum creatinine of less than 300 micromol/L and who had not had acute rejection within the last 6 months were eligible for entry. Patients were randomized either to continue on CsA (n=114) or to stop CsA and start azathioprine (Aza, n=102). All patients remained on prednisolone. Median follow-up was 93 months after transplantation (range: 52-133 months). RESULTS: There was no significant difference in actuarial 10-year patient or graft survival (Kaplan-Meier), despite an increased incidence of acute rejection within the first few months after conversion. Median serum creatinine was lower in the Aza group (Aza: 119 micromol/L; CsA. 153 micromol/L at 5 years after randomization, P=0.0002). The requirement for antihypertensive treatment was also reduced after conversion to Aza; 75% of patients required antihypertensive treatment at the start of the study, decreasing to 55% from 1 year after randomization in the Aza group and increasing to >80% in the CsA group (55% (Aza) and 84% (CsA) at 5 years after randomization, P<0.005). CONCLUSIONS: Conversion from CsA to Aza at 1 year after renal transplantation results in improvement in both blood pressure control and renal allograft function, and is not associated with significant adverse effects on long-term patient or graft survival.

Pre-operative echocardiographic abnormalities and adverse outcome following renal transplantation.

BACKGROUND: Premature cardiovascular disease is now the leading cause of death in renal transplant recipients. Although patients with progressive renal disease have many of the conventional risk factors for cardiovascular disease these do not have the same predictive power as they do in the general population. Echocardiographic abnormalities, notably left ventricular hypertrophy, have been shown to be associated with adverse outcome in patients on dialysis. METHODS: The echocardiograms were studied from 141 patients who were examined on the eve of renal transplantation between 1988 and 1990 to try to identify factors predicting outcome. Thirty-four patients have since died, 22 of cardiovascular disease. Ninety-three of the survivors and 27 of the dead patients had echocardiographic traces suitable for analysis. RESULTS: Left ventricular mass index was increased in those patients who died (median 167 vs 134 g/m2; P=0.03), as were end-systolic (4.3 vs 3.4 cm; P<0.01) and end-diastolic (5.8 vs 5.2 cm; P<0.01) diameters. Systolic function was also more severely impaired (fractional shortening, 27 vs 33%; P<0.01). Apart from age, only systolic function and end systolic diameter were independent predictors of outcome in multivariate analysis. CONCLUSIONS: This pattern of echocardiographic abnormality is similar to that reported in long-term dialysis populations, despite the adverse effects on survival. Moreover, despite potential benefits of transplantation on cardiac function, left ventricular hypertrophy, ventricular dilatation and systolic dysfunction were all associated with adverse outcome following transplantation. We conclude that echocardiography identifies markers for premature death following transplantation and provides targets for therapeutic intervention.

Nosocomial transmission of hepatitis C virus within a British dialysis centre.

Patients on renal replacement therapy are recognized as a group at increased risk of infection with hepatitis C virus (HCV). While the risk has been reduced by the use of erythropoietin for treatment of anaemia and the introduction of HCV screening of blood products and potential renal transplant donors, new cases of HCV are still being documented, with patients on hospital haemodialysis appearing to be particularly at risk. The exact mode of transmission of HCV within dialysis units is unclear, although there is evidence to support nosocomial transmission between patients. Third generation HCV antibody testing was performed on all dialysis patients when a new case of HCV was identified within our unit. Stored monthly serum samples were then examined retrospectively to determine when patients became HCV RNA and HCV antibody positive. Viral typing was carried out to identify the HCV strains responsible for transmission. Four new cases of HCV infection are described within a single dialysis shift. Viral typing identified two distinct strains of HCV as being responsible for these infections, both of which had previously been identified in dialysis patients within the unit known to have HCV infection. This information, taken in conjunction with knowledge of the location of each patient for dialysis, suggests two separate episodes of nosocomial transmission of HCV between haemodialysis patients. While evidence of nosocomial transmission of HCV is accumulating, with modern dialytic procedures evidence of transmission through the dialysis machine or equipment used for dialysis is lacking. This stresses the importance of strict applications of universal precautions as the key to prevention of further transmission of HCV infection. This information is obviously applicable not only to dialysis units but all units that may potentially come in contact with HCV patients.

Survey of patient selection for cadaveric renal transplantation in the United Kingdom.

The limited supply of cadaveric kidneys results in failure to offer transplantation to all dialysis patients who might benefit. To survey current UK attitudes to selection for renal transplantation and to assess the influence on these attitudes of the shortage of cadaveric donor kidneys, a questionnaire including 20 case histories was circulated to 190 nephrologists and transplant surgeons involved in renal transplantation in the UK. The response rate was 79%. The acceptance rate of individual patients for renal transplantation varied from 19 to 100% of respondents. Almost all patients were significantly (P < 0.05) more likely to be selected for transplantation if an adequate supply of kidneys were available. A correlation was noted between the responses from nephrologists working in Transplant Units and the percentages of their dialysis patients on transplant waiting lists (P < 0.01). This survey strongly suggests that more UK dialysis patients would be offered renal transplantation if the supply of cadaveric kidneys were adequate, and so the current national waiting list, although lengthy, understates the potential demand. Finally, this survey shows the wide variation that exists among both nephrologists and transplant surgeons in their attitude to patient selection for transplantation.

Hepatitis C virus infection in renal dialysis patients in Glasgow.

A survey of all 483 adult dialysis patients in the three renal units in Glasgow using second-generation ELISA was carried out to determine hepatitis C virus (HCV) seroprevalence in the summer of 1991 before the introduction of blood donor screening for antibody to HCV in the UK. Supplementary testing of ELISA positive sera was by second-generation immunoblot assay (RIBA-2, Chiron). Retrospective case note analysis and testing of stored sera were performed to assess liver function and the risk factors for acquisition of the virus. Nineteen of the 483 patients (3.9%) were seropositive. Sixteen patients had been transfused and 12 had previous transplants. Seropositivity was associated with current haemodialysis (P < 0.01) rather than continuous ambulatory peritoneal dialysis (CAPD). Of those on haemodialysis, the time since first dialysis was longer for seropositives (13.6 years) than for seronegatives (6.3 years) (P < 0.01) but this did not apply to those on CAPD. Twelve of 19 (63.2%) seropositives had persistent elevations of alanine transferase compared to seven of 38 (18%) seronegative controls (P < 0.01). This large group of dialysis patients is at special risk of HCV infection but the seroprevalence is less than that reported from outside the UK despite the use of more sensitive techniques. The risk is associated with haemodialysis and is probably largely due to blood transfusion. The introduction of screening of donated blood for HCV antibody should reduce the incidence of new infection in dialysis patients.

Problem-based learning packages: considerations for neophyte package writers.

Adopting problem-based learning (PBL) as the major educational approach in the implementation of a nursing curriculum requires the development of numerous learning stimulus packages. When reviewing the experience of the Division of Nursing within the Faculty of Health at the University of Western Sydney, Macarthur in Australia, several considerations for package writers were identified and are discussed. These include needs assessment, integration of the curricula content strands, multi-media learning stimuli, context, role and the incorporation of ongoing client management. The need for nurturance of writers and peer review of the developed packages is also addressed, as is a review of the impact of different learning stimuli.

Detection of lymphocyte Fc gamma receptor-blocking factors by the EA rosette inhibition assay. Refinement of the conventional method and development of a novel flow-cytometric assay.

Serum factors which interact with human peripheral blood lymphocyte Fc gamma receptors (Fc gamma Rs) may be detected in vitro by the EA rosette inhibition assay (EARIA). This assay has been used to detect circulating immune complexes and certain alloantibodies directed against cell surface antigens situated in close proximity to Fc gamma Rs. Three main types of FcR-blocking factor have been demonstrated by the EARIA in human serum following exposure to alloantigens. A strong correlation was observed between the presence of one of these FcR-blocking factors (FcBF1) and human renal allograft survival. This factor was previously shown to bind preferentially to CD32+ B cells and to inhibit antibody synthesis. In this study we have shown that detection of FcBF1 by the EARIA depends on the type of erythrocyte and on the amount of antibody used to sensitise the erythrocytes. Furthermore, we have developed a flow-cytometric version of the EARIA which is rapid, reproducible and, most importantly, objective. Inter-laboratory comparisons using this standardised EARIA should now be possible.

Immunosuppression in sclerosing peritonitis.

Sclerosing peritonitis (ScP) is a rare but fatal complication of continuous ambulatory peritoneal dialysis (CAPD), presenting as small bowel obstruction. We have observed that only patients receiving a renal transplant survived more than a few months after the diagnosis of ScP. We now report prolonged survival of patients given immunosuppressive therapy with or without a functioning transplant. ScP was found at laparotomy in 17 Glasgow patients, 15 of whom had been exposed to chlorhexidine in alcohol. All patients discontinued CAPD after diagnosis. Within a year 12 died with recurrent bowel obstruction; none received immunosuppressive therapy. The remaining 5 patients received immunosuppressive therapy; 4 are alive between 1 and 9 years later, and one patient with widespread vascular disease died after 3 years with mesenteric ischemia. Four of the 5 received a renal transplant. One patient rejected his transplant; when immunosuppression was stopped he developed symptoms suggestive of recurrent ScP. Immunosuppressive therapy was restarted and he remains well 3 years later. The fifth patient, who did not receive a transplant, was immunosuppressed after ScP was diagnosed. She remains well 18 months later. Our experience suggests that immunosuppression is beneficial in ScP.

Stakeholder evaluation: a model for decision making in problem-based learning.

Evaluation of new programmes in education are essential if one is to monitor the extent to which implementation is occurring in the manner that programme developers intended. This paper describes the use of a stakeholder approach in the evaluation of a nursing programme which uses problem-based teaching and learning strategies in curriculum implementation. Some background to the course is provided with a brief description of problem-based learning methodology. The central focus of the paper is on provision of an overview of a decision-making model of evaluation incorporating the stakeholder approach. It is suggested that this approach provided comprehensive feedback on the course implementation process, allowing for decision-making in relation to subsequent maintenance or modification of elements of a pre-service nursing programme.

Ultrasound changes in sclerosing peritonitis following continuous ambulatory peritoneal dialysis.

Sclerosis of the peritoneum, with encapsulation of the small bowel is one of the most serious complications of continuous ambulatory peritoneal dialysis (CAPD), and carries a high mortality. The abnormalities seen on ultrasound are described for 14 patients and comprise increased small bowel peristalsis, tethering of the bowel to the posterior abdominal wall, intraperitoneal echogenic strands and, in the late stages of the disease, membrane formation. Optimal visualization of these features in the early stages of the disease was obtained by examining the patients with dialysis fluid present in the abdomen. Sclerosing peritonitis should be suspected in patients being treated by CAPD who develop abdominal pain and progressive loss of ultrafiltration and subsequent investigation should include the use of ultrasound.

CD5-T lymphocytes in renal transplant recipients.

The CD3+CD5--subpopulation of T cells has been shown to be increased in patients following allogeneic bone marrow transplantation, and a statistical association has been found with graft-versus-host disease (GVHD). We studied this population in renal transplant recipients. There was no correlation with rejection episodes but we found an increase in this CD3+CD5--population in patients on cyclosporin, and we suggest that these cells may be involved in the mechanism of action of this drug. In patients on azathioprine the absolute number of CD3+CD5--lymphocytes is reduced, along with other lymphoid subpopulations.