Late low-dose steroid withdrawal in renal transplant recipients increases bone formation and bone mineral density.

Corticosteroids have been the most widely used immunosuppressive agents since the first clinical transplantation in the 1950s. There are few studies of late steroid withdrawal in renal transplantation and none have prospectively assessed bone mineral density (BMD). The study aim was to assess the impact of corticosteroid withdrawal, in stable renal transplant recipients, on BMD and bone turnover. BMD, osteocalcin (OC) and cross-linked telopeptide of type I collagen (CTx) were measured in 92 patients randomized into a trial of steroid withdrawal. Patients with functioning renal transplants for more than 1 year with a serum creatinine below 200 micromol/L entered the trial. All patients were on triple immunosuppression (Cyclosporin microemulsion, Azathioprine and prednisolone), corticosteroids were withdrawn at 1 mg/month. BMD was measured twice annually with serum CTx and OC. One year following withdrawal of glucocorticoids there was no significant difference in creatinine. BMD increased in the withdrawal group (2.54% per year L1-L4, p < 0.01), there was a slight reduction in the control group. Mean OC increased from 5.3 to 12.2 ng/mL (p < 0.05) in the withdrawal group, but was unchanged in the controls. No change was seen in CTx. Corticosteroid withdrawal in renal transplant recipients results in an increase in BMD with a corresponding increase in serum OC.

Noninvasive imaging of living related kidney donors: evaluation with CT angiography and gadolinium-enhanced MR angiography.

OBJECTIVE: This study was performed to determine whether noninvasive imaging with CT angiography and MR angiography in the preoperative investigation of living, related kidney donors provides sufficient information for the surgeon. MATERIALS AND METHODS: Eighty consecutive potential living kidney donors were investigated. Fifty patients underwent CT angiography and 30 underwent MR angiography before donor nephrectomy. CT was performed using 3-mm collimation with a pitch of 1.6 after the injection of 150 mL of nonionic contrast medium. The axial data, multiplanar reconstructions, and maximum intensity projections were reviewed. MR angiography was performed on a 1-T magnet using a contrast-enhanced three-dimensional gradient echo technique. Maximum intensity projections and axial reformations were reviewed. Imaging findings were compared with the surgical results in 54 patients. RESULTS: CT angiography and MR angiography were 100% sensitive in identifying the main renal arteries and renal veins. CT angiography visualized 37 of the 40 arteries identified at surgery, for a detection rate of 93%. MR angiography visualized 18 of the 20 arteries identified at surgery, a detection rate of 90%. CONCLUSION: CT angiography and MR angiography are suitable for the noninvasive investigation of living kidney donors and provide all the information required by the surgeon. Both methods may miss small accessory renal arteries. MR angiography does not use potentially toxic contrast material or radiation and is the preferred investigation, with CT angiography reserved for patients unable to tolerate MR imaging.

Antibody removal and subsequent transplantation of a highly sensitised paediatric renal patient.

We report a successful renal transplant in a highly sensitised paediatric recipient following removal of HLA-specific antibodies by extracorporeal immunoadsorption. The immediate pretransplant cytotoxic titre against the donor was greater than 1:512; this was reduced to negativity by two immunoadsorption sessions prior to transplant surgery. We also describe the presence of unexpected non-HLA-specific antibody activities in this immunoadsorbed patient.

Is cystoplasty a safe alternative to urinary diversion in patients requiring renal transplantation?

The study aimed to assess the methods of urinary drainage in patients requiring renal transplantation in whom the native lower urinary tract was unsuitable. Twenty-one patients had a transplant into an abnormal urinary tract. Eight of them into a cystoplasty, 8 into an ileal conduit and 5 had a cutaneous ureterostomy. All patients transplanted into an ileal conduit (mean follow-up 4.6 years) and into a cutaneous ureterostomy (mean follow-up 3.2 years) have had a satisfactory outcome. Five of 8 patients transplanted into a cystoplasty have had a satisfactory outcome, 2 patients suffered graft loss due to rejection and 1 developed necrosis of cystoplasty following transplantation. In terms of graft survival, excellent results in the medium term were obtained for transplantation with an ileal conduit or cutaneous ureterostomy. Cystoplasty was less successful but was not the direct cause of graft loss in any patient and as such is as safe a technique in patients with end-stage renal failure so long as care is taken to avoid the vascular pedicle at the time of transplantation.

The negative influence of delayed renal allograft function on longer-term graft survival in a pediatric population.

The influence of delayed graft function on renal allograft survival has been studied in a review of 322 renal transplants performed at one pediatric institution. The appearance of the first radionuclide renal scan was used to indicate early function in patients receiving their first cadaveric allograft. Patients whose first radionuclide renal scan showed both good renal perfusion and good function (n = 52) were compared with those whose scans demonstrated good perfusion but no function (n = 32). the actuarial graft survival of those with no function was significantly worse (P < .05). The difference in graft survival was not solely due to grafts lost in the early posttransplant period. Analysis of serial serum creatinine estimations suggests a process of continued inexorable nephron loss in some patients whose grafts showed a delay in achieving function.

The management of renal transplant artery stenosis in children by percutaneous transluminal angioplasty.

Between 1967 and 1989 in this unit 262 children (age at transplantation 9 months to 17 years, mean 9.6 years) had 345 renal transplants performed. Transplant artery stenosis (TAS) was found in 30 (8.7%) as demonstrated by arteriography, performed only when there was unexplained deterioration in transplant function, hypertension that was difficult to control, or in the presence of a vascular bruit. All patients with TAS except one had received a cadaveric allograft. From 1980 onward, percutaneous transluminal angioplasty (PTA) has been available for TAS, and this was attempted on 21 occasions in 16 patients. Nine patients demonstrated angiographic improvement following the procedure, and 7 showed immediate clinical improvement. On one occasion angioplasty precipitated graft loss. Five patients underwent planned corrective surgery, 4 after unsuccessful angioplasties. Our experience suggests that PTA should be the first method of intervention for TAS. Moderate success, both in angiographic and clinical terms, can be achieved, negating the need for surgery, while failure of PTA does not preclude surgical attempts at correction.

Arteriovenous fistulas complicating biopsy of renal allografts: treatment of bleeding with superselective embolization.

The use of superselective embolization was assessed as a treatment for bleeding from postbiopsy arteriovenous fistulas (AVFs) in renal transplants. AVFs commonly occur after biopsy procedures in renal transplants, but severe bleeding is rare. Transcatheter embolization can be used to control bleeding, but unless it is sufficiently selective, the procedure results in loss of significant amounts of renal parenchyma. During a 4-year period, embolization procedures were attempted in seven patients 30-65 years old. All had AVFs shown on arteriography. Five patients underwent embolization; occlusion occurred only in the branch supplying the AVF. In one patient with three large AVFs, two were found to have occluded the day after embolization was attempted. In another, an AVF occluded when superselective catheter position was achieved but before embolization. Catheter manipulation in these cases may have precipitated occlusion. In five cases, coaxial embolization techniques were used. Embolization materials consisted of coils in three cases: 0.038 in. (0.97 mm) in one case, 0.025 in. (0.64 mm) in one case, 0.018 in. (0.46 mm) in one case; 0.038 in. (0.97 mm) coils and gelatin foam particles in one case; and localized contrast extravasation in one case. Serum creatinine level was measured before and after embolization in all patients, and radionuclide studies were undertaken in three cases. In all patients, bleeding was effectively controlled. None of the patients showed an increase in serum creatinine level after embolization, and in four, significant improvement was seen. Nuclear medicine studies showed no loss of renal function and a dramatic improvement in one patient. No complications due to the procedure were seen. Our experience suggests that superselective embolization with coaxial catheter techniques is an effective method of treating bleeding from postbiopsy AVFs in renal transplants with minimal loss of renal parenchyma.

Novel antibodies associated with unexplained loss of renal allografts.

Using an endothelial/epithelial hybrid cell line, three different non-HLA antibody types have been identified by flow cytometry in patients who have rapidly rejected multiple renal allografts. These antibodies may be classified as anti-endothelial-monocyte, anti-activated endothelial cell, or anti-epithelial cell.

A prospective randomized trial of vagotomy in chronic duodenal ulceration: 4-year follow-up.

A total of 153 patients (124 male and 29 female) with uncomplicated chronic duodenal ulceration were studied in a prospective, randomized trial of proximal gastric vagotomy (PGV) and truncal vagotomy and pyloroplasty (TVP), conducted in four Manchester hospitals. Of these, 137 patients have now been followed up for 2.5 to 5.5 (mean 4.1) yr. There have been 15 (21 per cent) recurrent ulcers following PGV compared with 5 (7.5 per cent) after TVP (P less than 0.05). A satisfactory functional result was obtained in 82 per cent of patients after TVP compared with 73 per cent following PGV and there was little difference between the groups with regard to the incidence of dumping, heartburn and vomiting. There was significantly more diarrhoea following TVP (13 per cent) compared to PGV (1.4 per cent) but this represented only a minor clinical problem.

A prospective randomized trial of vagotomy in chronic duodenal ulceration.

In a prospective, randomized trial, 76 patients with duodenal ulceration treated by truncal vagotomy and pyloroplasty were compared with 77 patients who underwent highly selective vagotomy. A total of 149 patients was followed up for from 1 to 4 years, the average follow-up period being 2.6 years. There was no operative mortality and no significant difference in postoperative morbidity between the two groups. The incidence of recurrent ulceration was greater after highly selective vagotomy, but this difference was not statistically significant. The clinical results were comparable in each group, and although the incidence of diarrhoea and dumping was greater after vagotomy and pyloroplasty, this difference was not statistically significant.

Layer closure of laparotomy wounds with absorbable and non-absorbable suture materials.

Opinions vary regarding the best suture material for abdominal wound closure. Some surgeons favour non-absorbable sutures while others use absorbable materials, but there is little objective clinical information regarding the relative merits of the different suture materials. In a randomized prospective clinical trial the synthetic absorbable polyglactin and polyglycolic acid sutures were compared with the non-absorbable polypropylene suture in the closure of 161 laparotomy wounds. A layered closure technique was used in all cases. The total incidence of wound dehiscence and herniation was 8-1 per cent, and there was no significant difference between polylycolic acid (9-6 per cent), polyglactin (5-8 per cent) and polypropylene (8-8 per cent). Dehiscence and herniation were significantly more common in wounds closed by surgeons in training. It was concluded that none of the suture materials provided satisfactory freedom from wound complications. It is possible that these sutures may prove satisfactory with an alternative technique of abdominal wound closure, but this should be the subject of further clinical studies.