[Kidney transplant from living donor. Experience at the Jiménez Díaz Foundation]. / Transplante renal con donante vivo. Experiencia de la Fundación Jiménez Díaz.

OBJECTIVES: To discuss the organizational and surgical aspects, results, remarkable events and some ethical considerations of the renal transplantation program with grafts from living donors at our institution over a 25-year period. METHODS: The renal transplant program of the Jiménez Diaz Foundation began in 1964 and the first kidney graft from a living donor was transplanted in 1968. Since then and until December 1993, 157 renal grafts from living donors have been transplanted. The donors were parents in 94, siblings in 55 and the spouse in 4 occasions. Moreover, two free kidneys and two grafts from nonrelated donors were transplanted. The surgical procedure was also similar; i.e., right nephrectomy through a supracostal lumbotomy to remove the kidney and transplantation in the right iliac fosa with anatomosis to cava and common iliac or hypogastric artery. Changes in the surgical technique warranted by the intraoperative findings were infrequent. The ureter was anastomosed to the bladder using an extra- or transvesical technique depending on the surgeon's experience. Harvesting and transplantation of the kidney graft were performed simultaneously by two surgical teams. RESULTS: There were no major complications in the donors or technical difficulties or errors during harvesting that might have compromised graft viability, although complications such as hemorrhage, urinary fistula, thrombosis and prolonged anuria were observed early postoperatively. The incidence of grafts lost specifically related with the technique was less than 3%. Nineteen recipients had died early postoperatively from acute rejection and sepsis. Recipient and graft survival were basically related with the degree of histocompatibility and the changing therapeutic strategy over the 25-year period. The best results were found in 33 transplants involving HLA identical siblings, with a five-year actuarial survival rate of 89%, a 10- and 15-year survival of 70% and a 22-year survival of 22%, followed by those who were haploidentical who had donor-specific transfusions and the haploidentical cases treated with cyclosporine. The poorest results were seen in the historical group of 52 transplant procedures performed between 1968 and 1981 who were treated with the classical medication. CONCLUSIONS: The good results achieved and the minimal risk to donors demonstrated by our experience over a period of 25 years support continuation of the renal transplantation program with grafts from living donors, as well as our approach of having two surgical teams working simultaneously.

Increased severity of the acute renal failure induced by HgCl2 on rats with reduced renal mass.

In rats unilaterally nephrectomized 2 days before and sham operated controls, an acute fenal failure (ARF) has been induced by subcutaneous HgCl2 injection. The uninephrectomized animals showed a more severe ARF than the sham operated, 60% of the former and 10% of the controls became anuric 48 hours after ARF induction. The increased diuresis and natriuresis produced by acute saline overload did not improve the severity of the ARF. The marked difference in the evolution of this model of ARF with respect to the glycerol induced ARF, which is ameliorated by reduction of renal mass, emphasizes the different pathogenetic mechanism of these two experimental models.

Negative effect of frusemide pretreatment in glycerol induced acute renal failure.

It is commonly assumed that the decrease in the effective circulatory volume (ECV) is the major event in acute renal failure (ARF) and the preferential ischemia of the cortex another major modification. Frusemide has been given to try to prevent this change in glycerol-induced ARF because of its effect in redistributing renal blood flow from medulla to cortex. Isontonic saline was also tried to avoid the ECV depletion. The pretreatment with frusemide not only fails to protect against the ARF but increases its severity. Isotonic saline adminstration and replacement of urinary losses almost prevent glycerol-induced ARF but when both isotonic saline frusemide are administered together their effect is only a slight increase in the excretion rate of urea and creatinine during the first days of the experiment. The importance of the changes in the ECV or a possible direct action of frusemide on the renin-angiotensin axis are discussed. There is a good correlation between plasma creatinine levels and interstitial oedema. The importance of the oedema in the maintenance of ARF is discussed.