[Acute renal failure of the donor in encephalic death: A real contraindication to kidney transplantation?] / L'insuffisance rénale aiguë du donneur en mort encéphalique : une réelle contre-indication à la transplantation rénale ?

INTRODUCTION: The shortage of kidney transplants encourages the expansion of the limits of eligibility criteria for donation. Many donors who are brain dead display acute renal failure at the time of death; is this a real contraindication to harvesting? The aim of this study was to assess kidney graft survival from donors after brain death with confirmed acute renal failure, with or without anuria previous donation. MATERIALS AND METHODS: All of the transplants performed in two university hospitals between 2010 and 2017 were analyzed retrospectively. All patients who underwent single kidney transplant from a brain-dead donor with acute renal failure (ARF) were included in this study. ARI was defined here by a decrease over 50 % of glomerular filtration rate (GFR) to a threshold below 45mL/min/1.73 m2 at the time of kidney procurement. Kidney graft survival, incidence of delayed graft function (DGF) and the GFR at 12 months were analyzed. Analysis of kidney transplant survival based on pre-implantation biopsies was additionally done. RESULTS: One hundred and sixty four patients were transplanted with a kidney from donor with ARF during the selected period. At the admission in ICU the average GFR was 67,7±19mL/min/1,73m2. At the time of donation, the average age of donors was 56.4±17.7 years, the GFR was 33.7±8.0mL/min/1.73 m2 16 % of donors were anuric. Cold ischemia time (CIT) was 16.8±5.0hours. The average age of recipients was 55.6±14.1 years. 81 % of the cases were primary transplants. Graft function took place within 7.8±9.4 days after transplantation. There were two non-primary functions (PNF). One hundred and fifty two patients (93 %) had a functional graft at 12 months. The mean GFR at 12 months was 46.8±20.1mL/min/1.73 m2 and 122 patients (73 %) had a GFR greater than 30mL/min/1.73 m2. Seventy-one percent of preimplantation biopsies revealed acute tubular necrosis (ATU); no cortical necrosis was observed. Survival of theses grafts was 85 %, comparable to the total population of study (P=0,21) CONCLUSION: The acute renal failure of the brain-dead donor should not alone be systematically a contraindication to harvesting and kidney transplantation.

Early corticosteroid avoidance in kidney transplant recipients receiving ATG-F induction: 5-year actual results of a prospective and randomized study.

One hundred ninety-seven patients received anti-T-lymphocyte globulins Fresenius, mycophenolate mofetil and delayed cyclosporine, and were randomized to ≥6-month corticosteroids (+CS; n=99) or no CS (-CS; n=98). One- and five-year actual graft survival (censored for death) was 93.2% and 86.4% in the +CS group versus 94.9% and 89.8% in the -CS group (5-year follow-up, p=0.487). Freedom from clinical rejection was 86.9% and 81.8% versus 74.5% and 74.5% (p=0.144), respectively, at 1 and 5 years; 5-year freedom from biopsy-proven rejection was 88.9% versus 83.7% (p=0.227). More late first rejections occurred in the +CS group. Significantly lower 5-year graft survival in patients experiencing rejection was observed for +CS (55.6% vs. 92.0%; p=0.005) with 8/18 versus 2/25 graft losses. Renal function at 5 years was stable and comparable (median serum creatinine, 159 vs. 145 µmol/L; creatinine clearance, 53.5 vs. 56.6 mL/min). More +CS patients developed diabetes, dyslipidemia and malignancies. Rejections in -CS patients occurred early after transplantation and did not impair long-term renal function. In patients receiving CS, rejections occurred later and with a higher risk for subsequent graft failure. A similar and not inferior 5-year efficacy profile and a reduced morbidity were observed in CS-free patients compared to patients who received CS for at least 6 months.

Banff schema for grading pancreas allograft rejection: working proposal by a multi-disciplinary international consensus panel.

Accurate diagnosis and grading of rejection and other pathological processes are of paramount importance to guide therapeutic interventions in patients with pancreas allograft dysfunction. A multi-disciplinary panel of pathologists, surgeons and nephrologists was convened for the purpose of developing a consensus document delineating the histopathological features for diagnosis and grading of rejection in pancreas transplant biopsies. Based on the available published data and the collective experience, criteria for the diagnosis of acute cell-mediated allograft rejection (ACMR) were established. Three severity grades (I/mild, II/moderate and III/severe) were defined based on lesions known to be more or less responsive to treatment and associated with better- or worse-graft outcomes, respectively. The features of chronic rejection/graft sclerosis were reassessed, and three histological stages were established. Tentative criteria for the diagnosis of antibody-mediated rejection were also characterized, in anticipation of future studies that ought to provide more information on this process. Criteria for needle core biopsy adequacy and guidelines for pathology reporting were also defined. The availability of a simple, reproducible, clinically relevant and internationally accepted schema for grading rejection should improve the level of diagnostic accuracy and facilitate communication between all parties involved in the care of pancreas transplant recipients.

[Dialysis-associated spondyloarthropathy. Case report and literature review]. / La spondylarthropathie érosive du dialysé rénal. A propos d'un cas, revue de la littérature.

Hemodialysis has considerably prolonged the life of patients suffering from terminal renal failure. However, long-term hemodialysis leads to new bone complications and spinal disorders such as destructive spondyloarthropathy (DSA). At the present time DSA is reported in 8% to 18% of the dialysed patients. Diagnosis is based on severe narrowing of the intervertebral disk, erosions and geodes of the adjacent vertebral plates simulating infectious spondylitis. Lesions progressively involve posterior joints and may lead to severe destruction of the spine. The pathogenesis of this syndrome is still unknown. Several factors have been implicated, including microcrystal deposition, amyloidosis, inflammatory and foreign body reactions and suggest that the pathogenesis of erosive spondyloarthropathies of hemodialysed patients is multifactorial. Spinal instability inducing myelopathy and radiculopathy were observed in 8% of the cases. Treatment must be accorded to the natural disease course and to the quality of the bone. We report the case of a chronic dialysed patient with destructive spondyloarthropathy involving the cervical and thoracic spine. Pathogenesis, radiological datas and therapeutic approach are discussed.

Prevention of acute rejection with antithymocyte globulin, avoiding corticosteroids, and delaying cyclosporin after renal transplantation.

BACKGROUND: Despite their well-known side-effects, corticosteroids (Cs) are currently used after kidney transplantation. Avoidance of Cs may improve patient quality of life and eventual long-term survival. We report on a regimen using antithymocyte globulin (ATG) and mycophenolate mofetil (MMF) for induction, and cyclosporin (CsA) plus MMF for maintenance treatment of recipients of primary kidney transplantation. METHODS: We studied 11 consecutive, non-sensitized renal transplant patients (nine cadaver and two living donors). Initial immunosuppression consisted of ATG (1.5 mg/kg/day, i.v.) given for 10 days and MMF (1.0 g/b.i.d.). CsA (8 mg/kg, in two divided doses) was started on post-operative day 11. Cs were only allowed in the case of MMF discontinuation, for the treatment of acute rejection, and in the event of recurrence of the primary glomerulonephritis. RESULTS: All patients completed the entire 10-day ATG course. Main side-effects included fever (>38 degrees C) and serum sickness, observed in 73 and 27% of the patients respectively. The incidence of acute rejection was 27% (three of 11 patients). In two patients with acute rejection, serum sickness was concomitantly diagnosed and renal histology was partially compatible with immune-complex disease. The remaining patient had two episodes of low-grade rejection. All rejection episodes were rapidly reversed. Two patients (18%) were treated with ganciclovir for cytomegalovirus (CMV) infection. Two patients (18%) are currently receiving Cs for recurrence of the native glomerulonephritis and two rejection episodes respectively. All patients are currently alive with functioning kidneys (average follow-up of 8.4 months; average creatinine level of 128 micromol/l). CONCLUSION: This pilot study suggests that ATG induction in combination with MMF and delayed introduction of CsA, in the absence of Cs, is not well tolerated in recipients of kidney transplants. An earlier introduction of calcineurin inhibitors and/or a shorter course of ATG may reduce the incidence of fever and serum sickness secondary to ATG.

Clinical relevance of direct quantification of pp65 antigenemia using flow cytometry in solid organ and stem cell transplant recipients.

A total of 1,305 blood samples from 85 solid organ transplant (SOT) recipients and 25 stem cell transplant (SCT) recipients at risk for cytomegalovirus (CMV) infection were prospectively collected and tested using the shell vial assay (SVA) and a leukocytic qualitative PCR (q-PCR). Of these, 462 specimens were further tested by direct quantification of CMV antigenemia by flow cytometry (FC-Ag), 125 were tested with a quantitative competitive PCR, and 200 were tested for pp65 antigenemia using the slide method (S-Ag). Laboratory data were statistically analyzed according to the presence of CMV-related symptoms. In SOT and SCT recipients, active CMV infection occurred in 63.5 and 36%, respectively, and CMV disease occurred in 53 and 24%, respectively. FC-Ag results correlated better with q-PCR and S-Ag than with SVA. The first test found to be positive during follow-up was FC-Ag in 73% of cases. In SOT recipients, FC-Ag showed the highest sensitivity and negative predictive value for the diagnosis of any grade of CMV disease. For FC-Ag, the threshold beyond which CMV disease was highly probable seemed to lie at 0.20% positive polymorphonuclear leukocytes. FC-Ag appears to be a useful test for the early detection of CMV infection and the prediction of CMV disease.

Efficacy Endpoints Conference on Acute Rejection in Kidney Transplantation: review of the conference questionnaire.

Basic differences in the diagnosis and management of acute rejection in renal transplant can be found between centers. A questionnaire was developed to ascertain the profile of these variables. Sixteen fundamental questions were presented to the program directors of 17 transplant groups from around the world. The questions were brief and designed to identify clinical practice and behaviors related to the definition of acute and steroid-resistant rejection, successful response to therapy, use of histological diagnosis, estimated frequency of rejection, and frequency of mild, moderate, or severe acute rejections. Clinicians were presented with case studies and asked to respond to specific questions regarding the rejection management described in these cases to determine similarities in management practices. Results indicated that clinicians relied on clinical symptoms only rarely. Biopsy findings were used by 53% of clinicians, and 94% of clinicians indicated that rejection was suspected if creatinine increased. Successful response was defined as a return to prerejection creatinine level by 77% of clinicians and that steroid-resistant rejection is evident by 5 days. Biopsy was used by 80% of centers to diagnose first acute rejection episode, and only 18% of rejection episodes are expected to be severe. This report was then used to develop a more detailed questionnaire to be used in profiling acute rejection in consecutive transplant recipients.

Effect of long-term immunosuppression in kidney-graft recipients on cancer incidence: randomised comparison of two cyclosporin regimens.

BACKGROUND: Long-term administration of cyclosporin carries a risk of renal toxicity, and immunosuppressants are associated with an increased rate of malignant disorders. We undertook an open randomised study of the risks and benefits of two long-term maintenance regimens of cyclosporin in kidney-allograft recipients. The primary endpoint was graft function; secondary endpoints were survival and occurrence of cancer and rejection. METHODS: 231 recipients of a first allograft with at most one previous rejection episode were randomised 1 year after transplantation. Most were receiving cyclosporin and azathioprine. One group received cyclosporin doses adjusted to yield trough blood concentrations of 75-125 ng/mL (low-dose group); the second received doses that yielded trough concentrations of 150-250 ng/mL (normal-dose group). Analysis was by intention to treat. FINDINGS: At 66 months' follow-up, the low-dose and normal-dose groups were similar in mean serum creatinine (182 [SD 160] vs 184 [157] micromol/L; p=0.9) and mean creatinine clearance (47.5 [25.1] vs 45.3 (22.5] mL/min; p=0.6). Nine of 116 patients in the low-dose group and one of 115 in the normal-dose group had symptoms of rejection (p<0.02). There was no difference between the low-dose and normal-dose groups in survival (95 vs 92%; p=0.7) or graft survival (89 vs 82%; p=0.17) at 6 years. 60 patients developed cancers, 37 in the normal-dose group and 23 in the low-dose group (p<0.034); 66% were skin cancers (26 vs 17; p<0.05). INTERPRETATION: We found no evidence that halving of trough blood cyclosporin concentrations significantly changes graft function or graft survival. The low-dose regimen was associated with fewer malignant disorders but more frequent rejection. The design of long-term maintenance protocols for transplant recipients based on powerful immunosuppressant combinations should take these potential risks into account.

Development of a method for direct quantification of cytomegalovirus antigenemia by flow cytometry.

Cytomegalovirus (CMV) antigenemia was directly detected in polymorphonuclear leukocytes (PMNLs) from transplant recipients by using flow cytometry (FC). Two fixation and permeabilization methods and seven anti-CMV monoclonal antibodies (MAbs) were evaluated. 1C3, SL20, and NEA-9221 MAbs were more efficacious. The antigenemia detection threshold of FC was 0.05% positive PMNLs, and percentages correlated well with DNA viral load and the appearance of clinical symptoms.

Single-center analysis of 468 first cadaveric kidney allografts with a uniform ATG-CsA sequential therapy.

Progress in clinical management and sophistication of immunological treatment of kidney allografts depend upon continuous reassessment of the risk factors related to pre- and post-graft information according to the therapeutical strategies used. We studied predictive factors of long-term graft survival (up to 9 years) and of kidney graft function at one year after surgery in a single-center population of 468 first cadaveric kidney recipients treated with a uniform immunosuppression induction regimen of anti-thymocyte globulin, followed by cyclosporine A. The statistical analysis showed that long-term graft survival was highly correlated with the occurrence of one or more acute cellular rejections and with the timing of these episodes. In addition, this uniformly treated series of patients confirmed the potential importance of gender matching. The magnitude of anti-HLA immunization and delayed graft function were also strongly linked to low graft survival rates. We found no significant influence of HLA matching, with serological HLA typing, on graft loss. The quality of graft function at one year was found to be a strong prognostic factor of long-term graft survival. In addition, the impact of pre- and post-graft parameters were studied in terms of prediction of one-year graft function. A stepwise multivariate analysis showed that graft function at one year was a multivariate phenomenon strongly correlated with a history of acute rejection episodes and with donor and recipient age. However, these 3 factors could account for only 15% of the graft function deterioration, the remaining 85% might be explained in part by chronic cyclosporine toxicity and/or chronic rejection.

Decreased anti-donor major histocompatibility complex class I and increased class II alloantibody response in allograft tolerance in adult rats.

Permanent tolerance to allografts can be induced in adult rats by donor-specific transfusions (DST) prior to transplantation. We have previously reported, in a model of heart allograft, the presence of a heavy leukocyte infiltrate, in the allograft which displayed a strong allospecific cytotoxicity when tested in vitro against donor cells, and a strong accumulation of mRNA for granzyme A and perforin in vivo. In contrast, there was a major decrease in the accumulation of mRNA for interleukin-2 and interferon-gamma. These results suggested that the DST-induced tolerance was associated with a decrease in type-1 T helper (Th1) cell function. The major role of preformed antibodies in xeno and allorejection is clearly established. Nevertheless, the consequences of alloantibody production in acute rejection and tolerance induction remains to be elucidated. We here analyze the alloantibody response in rejecting and DST-treated recipients. We show that, after transplantation, tolerant recipients, in contrast to rejecting ones, mount a low IgM alloresponse that switches to low IgG production. Detailed analysis of IgG alloantibodies in DST-treated recipients revealed that their production decrease was not equally distributed. Whereas rejecting animals mounted a strong anti-class I and II IgG alloantibody response, DST-treated recipients produced anti-class II and low titers of anti-class I IgG alloantibodies. Furthermore, among IgG subclasses, tolerant recipients predominantly produced IgG2a, a profile which, in the rat, is compatible with a Th2-controlled response. Finally, the passive transfer of immune serum from rejecting animals to DST-treated recipients could abrogate the tolerance. We suggest that the absence of anti-class I alloantibodies combined with preserved and/or increased anti-class II production plays a major role in graft tolerance in this model. These results reinforced the role of alloantibodies in rejection and in induction of tolerance.

Prevention of acute rejection episodes with an anti-interleukin 2 receptor monoclonal antibody. II. Results after a second kidney transplantation.

The focus of progress in transplantation immunosuppression is to achieve more specific immunosuppression with monoclonal antibodies. We have already shown that the efficacy of 33B3.1, a rat monoclonal Ig2A directed against the human IL-2 receptor, was similar to that of rabbit antithymocyte globulin in the prevention of acute rejection in first kidney transplants. A similar comparative analysis has been made in 40-sec renal transplants. ATG (1 mg/kg/day) or 33B3.1 (10 mg/day) was administered during the first 10 days postgrafting in association with corticosteroids and azathioprine. Cyclosporine was introduced on day 9 and azathioprine/CsA constituted the patient's maintenance treatment after day 45. Rejection treatment consisted of equine antilymphocyte globulin in both cases and of steroid boluses when patients were under Cyclosporine. One patient in each group died. Graft survival was 90%, 85%, and 79% in the ATG group (n = 20) and 100%, 89%, and 89% in the 33B3.1 group (n = 20) at 3, 12, and 24 months, respectively. Of the ATG group patients, 45% and 40% in the 33B3.1 group had at least one rejection episode, half the episodes in the MoAb cohort occurring under 33B3.1, vs. none in the ATG group. Transplant function was similar in both groups. Viral infections appeared to be more frequent with ATG (60%) than with 33B3.1 (12%), with CMV accounting for half of these in the ATG group, and none in the MoAb group. Tolerance of both agents was good. Of the 33B3.1 recipients, 70% developed anti-33B3.1 antibodies. From these data, we conclude that this anti-IL-2 receptor MoAb seems less effective than rabbit ATG as induction treatment in second kidney transplant patients.

Prevention of acute rejection episodes with an anti-interleukin 2 receptor monoclonal antibody. I. Results after combined pancreas and kidney transplantation.

A prospective, randomized trial was conducted to evaluate the short-term and long-term effects of induction immunosuppression with the rat IgG 2a monoclonal antibody 33B3.1, directed against the human alpha chain of the interleukin 2-receptor, following primary, cadaveric, combined pancreas and kidney transplantation. Forty patients were randomly assigned to receive 10 mg/day of 33B3.1 (n = 20) or 1.5 mg/kg/day of rabbit antithymocyte globulin (n = 20) for the first 10 postoperative days. Azathioprine, low-dose corticosteroids, and cyclosporine were given in association with either 33B3.1 or ATG. All 40 patients received the entire 10-day bioreagent course and no episode of rejection was observed during this period. Although the incidence of rejection did not significantly differ within the first, second, and third postoperative months (ten 33B3.1 and 6 ATG patients experienced, respectively, 10 and 6 rejection episodes within the first 3 months), the total number of 33B3.1 patients experiencing rejection throughout the follow-up was significantly higher than that of ATG (13 versus 6; P < 0.02). Immunological graft failure accounted for 2 pancreas and 2 kidney losses in the 33B3.1 group versus 1 in the ATG one (P = ns). The total number of infectious episodes was similar in both groups (21 versus 23). Two malignancies were observed in the ATG group (1 responsible for patient's death). One 33B3.1 patient died because of infectious pneumonia and 3 ATG patients died because of 2 cardiovascular diseases and 1 cancer. All patients had functioning grafts at the time of death. The 3-month and 36-month patient, pancreas, and kidney actuarial survival rates were, respectively, 100, 65, and 100%, and 95, 50, and 82% in the 33B3.1 group and 95, 80, and 90%, and 80, 70, and 80% in the ATG one (P = ns). These data suggest that, although a significantly higher rejection episode incidence was observed in patients treated with 33B3.1 monoclonal antibody as compared with ATG, similar long-term results can be obtained following primary cadaveric combined pancreas/kidney transplantation.

Cadaveric renal transplantation after 60 years of age. A single center experience.

We report the outcome of 121 cadaveric renal transplants performed in our institution between September 1985 and April 1992 in 117 patients, aged 60-71 years (mean 63 years) at the time of transplantation. Compared to 640 patients 20-59 years of age transplanted during the same study period, a nonstatistically significant difference was observed in the 5-year actuarial patient (80% and 90%, respectively, in recipients over and under 60 years of age) and transplant (80% and 72%, respectively, in recipients over and under 60 years of age) survival rates. However, elderly patients had significantly lower survival than recipients 20-29 years of age (P < 0.009). Fourteen patients died (all but one with a functioning graft) due to cardiovascular diseases (5%; 42.8% of total deaths), infections (3%; 28.6% of total deaths), and gastrointestinal complications (3%; 28.6% of total deaths). Younger patients showed a similar and nonsignificantly different incidence of cardiovascular- (35%) and infectious-(30%) related deaths. The incidence of acute rejection episodes and cytomegalovirus (CMV) infectious episodes was 27% and 24%, respectively, during the 1st post-transplant year. Ongoing acute rejection and CMV infectious episodes were significantly higher in patients who died than in those still alive (P < 0.002 and P < 0.02, respectively). Cyclosporin maintenance therapy was well tolerated in all patients but one, and 64% of the patients could be maintained without steroids. These data indicate that cadaveric renal transplantation is a safe and effective procedure in the management of chronic renal failure of selected patients 60 years of age or older.

Renal transplantation from cadaver donors over 60 years old.

The influence of donor age on the short- and long-term outcome of cadaveric kidney transplantation was analyzed at our institution. During a 6-year period, 34 and 806 patients underwent kidney transplantation from cadaver donors over or less than age 60, respectively. Graft and patient survivals were compared throughout follow-up and herewith reported. In addition, main medical and surgical complications among recipients of elderly cadaver donors are detailed.

Prospective randomized comparison of University of Wisconsin and UW-modified, lacking hydroxyethyl-starch, cold-storage solutions in kidney transplantation.

University of Wisconsin cold storage solution differs from Euro-Collins by the presence of adenosine, allopurinol, and hydroxyethyl starch, which maintains osmotic pressure. It is now experimentally and clinically well established that the use of UW solution is associated with better liver graft recovery parameters after prolonged cold ischemia time. However, it has been also suggested in animal experiments that HES might not be essential for optimal kidney preservation, at least when cold ischemia time remains within 48 hr. Herein, we present a randomized study comparing UW (n = 44) and a modified UW (UW-mod) (n = 44) solution lacking HES, adenosine, and allopurinol on kidney graft recovery parameters. Forty-one consecutive Euro-Collins flushed kidneys, transplanted immediately before this randomized trial, were used as historical controls. The results indicate that UW-mod was as efficient as UW in preserving the kidney in cold ischemia ranges that did not exceed 48 hr. Both solutions (UW and UW-mod) seemed more effective than Euro-Collins, based on the analysis of several parameters including the number of days until the creatinine was < 300 microM (P < 0.05), the level of the serum creatinine at one month (P < 0.02), and the Cockroft index (P < 0.04). Since UW-mod is three times less expensive than UW, we suggest that the simplified solution could be routinely used to preserve kidneys for transplantation.

Evidence that early acute renal failure may be mediated by CD3- CD16+ cells in a kidney graft recipient with large granular lymphocyte proliferation.

We report here on a patient with a large granular lymphocyte proliferative disease who received a third kidney allograft. This patient presented a lymphocytosis (culminating at approximately 30,000/mm3) with a large proportion (approximately 70%) of CD3- WT31- CD2+ CD16+ lymphocytes. Five days after a kidney graft and during prophylactic treatment by Ortho pan OKT3, he presented an acute graft failure with an apparent interruption of graft blood flow as assessed by the Tc99 scan pattern and an arteriogram. The biopsy showed an abnormal accumulation of intravascular CD3- CD16+ cells bound to endothelial cells with thrombilike patterns in small and middle-sized arteries, whereas CD3+ mononucleated cells infiltrate was restricted to interstitium as observed in his previous graft, performed before the appearance of the lymphoproliferative disorder. The syndrome resolved spontaneously. The role of OKT3-mediated release of cytokines able to upregulate endothelial cell adhesion molecules in triggering this phenomenon is discussed.

Recurrent nephrotic syndrome following renal transplantation in patients with focal glomerulosclerosis. A one-center study of plasma exchange effects.

Forty seven renal allografts performed over a period of 12 years in 43 recipients with chronic renal failure due to biopsy-proved focal glomerulosclerosis (FGS, 5.34% from 888 cadaveric renal transplantations) were reviewed. Recurrence of the disease was suspected in 14 grafts (29.8%) on the basis of immediate proteinuria, but recurrence of FGS lesions was demonstrated in only 7 patients. The remaining 7 patients had minimal-change nephropathy or mesangial hyperplasia. The duration of renal disease before transplantation was a clear predictive risk factor of FGS recurrence, and mesangial hyperplasia in the native kidneys was associated with 50% risk of FGS recurrence. Some reports have suggested that plasma exchange may be beneficial in the treatment of FGS recurrence. Our experience, in 9 patients, indicates that plasma exchange initiated early in the course of recurrent proteinuria leads to transient but significant disappearance (2 cases) or decrease (5 cases) of proteinuria, with a return to pre-plasma exchange levels within 2 weeks after the end of treatment. In 2 cases, there was no beneficial effect on proteinuria. Plasma exchange efficacy was correlated with proteinuria levels relative to disease severity. Although plasma exchange does not seem to improve the outcome of FGS recurrence, it demonstrates the possible presence of circulating factor(s) and argues for the characterization of humoral mediator(s).

Assessment of coronary artery disease by thallium scan in type-1 diabetic uremic patients awaiting combined pancreas and renal transplantation.

Twenty-five type-1 diabetic uremic patients (14 men, 11 women, mean age forty +/- eleven years, range, nineteen to sixty) were prospectively analyzed for coronary artery disease (CAD) by thallium scan (TLS) before synchronus pancreas and kidney transplantation. Duration of diabetes ranged from ten to thirty-two years (mean twenty-two +/- five). Fifteen patients (60%) were in dialysis from two to sixty months (mean twenty +/- eighteen). Advanced diabetic degenerative complications were present in all patients. Twenty exercise and five pharmacologic thallium scans were performed. Forty-four percent of patients (6 men, 5 women, mean age forty-two +/- eleven years, range, twenty-six to sixty) had a positive (reversible or permanent defects) TLS. In 2/11 cases, severe CAD required further cardiac investigations for therapeutic management decision. A statistical correlation with resting ECG nonspecific ST-segment and T-wave abnormalities was observed (p less than 0.05) despite the absence of angor in 8 of the 11 patients. On the contrary, no statistical correlations were found regarding high blood pressure, smoking, hypercholesterolemia, duration of diabetes, and duration of dialysis. In this particular diabetic population (young age, male/female ratio = 1.2) with high incidence of silent ischemia, resting ECG repolarization abnormalities, though predictive, were not specific or prognostic of CAD severity; in these cases, exercise and pharmacologic TLS, a noninvasive and sensitive cardiovascular test, may be of great interest in diagnosis of CAD, allowing adequate cardiac management before, during, and after pancreas transplantation.