Disseminated histoplasmosis presenting as urinary tract obstruction in a renal transplant recipient.

Disseminated histoplasmosis occasionally involves the kidney, but the infection usually does not cause either urinary symptoms or a decrease in renal function. We present a case of disseminated histoplasmosis in a renal transplant recipient who presented with urinary obstruction in the allograft from a sloughed renal papilla infected with the fungus. At the same time the patient had chronic meningitis from Histoplasma capsulatum. The literature on renal involvement with histoplasmosis is reviewed.

Carcinoma in a transplanted kidney detected with MAG3 scintigraphy.

We report on two cases of infiltrative renal tumor developing in two kidney transplant recipients from a single cadaveric donor source. Interestingly, while this is only the second case of a de novo renal allograft tumor, both were morphologically infiltrative. The fact that both tumors were infiltrative may be secondary to immunosuppression therapy. While computed tomography (CT) evaluation of suspected renal pathology provides excellent anatomical detail, renal transplant recipients are initially evaluated using ultrasound and renal scintigraphy to avoid contrast reagents which could further impair renal function, as well as to reduce the image procedure cost and the patient radiation dose. Unfortunately, infiltrative tumors may be isoechoic on ultrasound, providing a confusing or conflicting report when compared to scintigraphic findings. This case report is significant radiographically because the original neoplasm was initially detected using technetium-99m-labeled mercaptoacetyltriglycine (99mTc-MAG3) scintigraphy and was not appreciated by sonographic studies, even retrospectively. This case demonstrates the usefulness of 99mTc-MAG3 scintigraphy to follow-up evaluations of renal transplants by providing detailed anatomical information as well as functional analysis of the kidney.

The effect of polyimmune gammaglobulin for prophylaxis against reactivation cytomegalovirus infection in kidney and kidney/pancreas transplant recipients.

Cytomegalovirus (CMV) remains the most important infection in the renal transplant recipient. Few data are available that provide guidance for approaches that seek to reduce the reactivation of latent disease after transplantation. To test the efficacy of polyimmune gammaglobulin in kidney and kidney/pancreas transplantation, consenting recipients with serologic evidence of previous CMV disease were randomized to receive i.v. polyimmune gammaglobulin (500 mg/kg) within 3 days of transplant with 250 mg/kg at weeks 1, 2, 4, and 6 or no prophylaxis. Both groups received identical induction and rejection immunosuppressive therapy. Polyimmune gammaglobulin prophylaxis reduced CMV reactivation infections. The incidence of reactivation infections was half in patients receiving Nashville/rabbit antithymocyte serum (N/R-ATS) compared with those receiving monoclonal anti-CD-3 therapy. Patients receiving polyimmune gammaglobulin along with N/R-ATS had an incidence of infection of only 10%. Reactivation infections were twice as common in patients who had primary nonfunction and nearly three times as common in patients with acute rejection. Both risk factors were associated with longer anti-T-cell therapy. Polyimmune gammaglobulin prophylaxis should be considered in transplant patients with previous CMV exposure who will be receiving prolonged anti-T-cell therapy because of acute rejection or primary nonfunction.

Colonic screening prior to renal transplantation and its impact on post-transplant colonic complications.

Colonic complications after renal transplantation are uncommon but have a high mortality rate. Some have recommended colonic screening in patients over 50 years of age prior to transplantation to lessen the impact of colonic diverticular disease. We report our 9-year experience of colonic screening for diverticular disease in potential recipients over the age of 50 and compare these results to the overall colonic complication rate in the same time period. From 1981-1990, 1186 renal transplants in 1019 patients were performed, during which time all potential recipients over the age of 50 yr were required to undergo colon evaluation prior to transplantation. Twenty cases of diverticular disease were found with more than a quarter of the cases in patients with adult polycystic disease. All underwent renal transplantation without a pre-transplant colectomy, and none had post transplant symptomatic colon disease. During that same time period a total of 14 colonic complications requiring surgical intervention were encountered with a mortality rate of 40%. Acute diverticulitis occurred in 5 patients, all of whom were over 50 yr of age, on low-dose immunosuppression, and in most cases it occurred remotely after transplantation. Colonic dysplasia/neoplasia also occurred remotely after transplantation in 2 patients over the age of 50. Cytomegalovirus (CMV) colitis was the next most common complication, accounting for 3 cases. This complication, which occurred in younger patients, was associated with high-dose steroid immunosuppression and had a high mortality rate, in spite of surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Single-center analysis of impact of immunosuppressive therapy upon renal allograft survival in the black population.

The effect of race upon renal allograft survival is controversial. Between 1981 and 1987, at Vanderbilt University Medical Center, 448 patients (75 black, 373 white) received azathioprine, 3 mg/kg daily; prednisone, 30 mg daily; and intravenous antithymocyte sera, 0.2 mL/kg/day for 14 days, after transplantation. Prednisone doses were decreased gradually to 10 mg daily within 6 months of transplantation. Azathioprine was maintained at doses of 2 to 3 mg/kg/daily; lower doses were administered if significant myelosuppression occurred. One-year graft survival was 72% and 85% among black and white recipients, respectively (P less than .01). Two hundred thirty-six patients have been treated with azathioprine (3 mg/kg initially tapered during the first week to 1.5 to 2 mg/kg); prednisone, 30 mg daily; and cyclosporine, 10 mg/kg per day. Cyclosporine therapy was begun after recipient serum creatinine levels had decreased below 3 mg/dL. Before therapy was initiated and until levels of cyclosporine were maintained between 150 and 200 ng/mL (whole blood), antithymocyte serum was administered. This immunosuppressive protocol resulted in 1-year graft survival of 90% and 87% in black and white recipients, respectively. Not only was graft loss markedly reduced, but the interracial difference noted before the use of cyclosporine was no longer evident. The type of immunosuppressive therapy used clearly affected 1-year allograft survival among black recipients. The combination of azathioprine, cyclosporine, and prednisone resulted in improved graft survival overall, but had the most significant effect among blacks.

Treatment of idiopathic retroperitoneal fibrosis by immunosuppression.

Idiopathic retroperitoneal fibrosis is exceedingly uncommon in childhood and its etiology is uncertain. Support for an immunological basis for the disease is given by a report of a 14-year-old girl with severe retroperitoneal fibrosis causing progressive azotemia in whom azathioprine and prednisolone were used successfully. This case supports the efficacy of immunotherapy in the treatment of idiopathic retroperitoneal fibrosis.

Glomerular hypertrophy in minimal change disease predicts subsequent progression to focal glomerular sclerosis.

The study sought a diagnostic clue to identify the group of pediatric patients with apparent minimal change disease who subsequently develop focal glomerular sclerosis (FGS). Review of all renal biopsy material at our institutions identified 42 pediatric patients who met the standard criteria for minimal change disease (MCD) on initial biopsies. Of those, 10 deteriorated clinically and on rebiopsy showed focal glomerular sclerosis (FGS). The initial renal biopsies of these 10 patients were analyzed morphometrically to determine the mean glomerular tuft area (GA). The results were compared to those of the remaining 32 patients whose subsequent benign clinical course was consistent with MCD, and to randomly selected, age-matched autopsy controls without renal disease (CONT, N = 10). The mean age was comparable among the three groups studied. Separate groups of adult (N = 12) and pediatric (N = 18) patients with initial biopsies with FGS were also studied. The initial biopsy of pediatric patients who subsequently showed FGS (rebiopsy performed on average 3.3 years later) had an average GA of 13.5 x 10(-3) mm2, 76% larger than glomeruli from children with MCD (7.7 x 10(-3) mm2, P less than 0.0005) and 62% larger than CONT (8.4 x 10(-3) mm2, P less than 0.005). Patients with FGS on initial biopsy, whether adult or pediatric, also had significantly larger GA than the age-matched MCD or CONT groups. Evaluation of GA in all the 42 pediatric biopsies with initial MCD further showed that in 23 patients GA was equal to or smaller than the CONT average.(ABSTRACT TRUNCATED AT 250 WORDS)

Living related kidney donors. A 14-year experience.

Living related donor (LRD) nephrectomies are controversial due to the risks to the donor and improved cadaveric graft survival using cyclosporine A. Between December 22, 1970, and December 31, 1984, 1096 renal transplants were performed at a single institution, 314 (28.6%) from LRD. The average age was 34.3 years (range: 18-67); none had preoperative hypertension. All nephrectomies were performed transabdominally. Major perioperative complications occurred in 22 (7.0%). These include wound infections (3.5%), pancreatitis (1.0%), injuries to spleen (1.0%) or adrenal gland (0.3%) requiring removal, pneumonitis (0.6%), ulnar nerve palsy (0.6%), femoral artery thrombosis after arteriogram (0.3%), pulmonary embolus (0.3%), and upper pole infarct of contralateral kidney (0.3%). There are six known deaths in this series, none of which were related to the operation. Major late complications were seen in 50 (20.0%) of 250 patients followed for 6 to 175 months (mean 53.1 months). These included definite hypertension (5.6%), suture granuloma (4.4%), incisional hernia (3.6%), proteinuria (2.4%), bowel obstruction (2.0%), nephrolithiasis (1.2%), wound infection (0.4%), scrotal hydrocele (0.4%), and chronic pancreatitis (0.4%). While the risk of hypertension appears to increase as the interval from donation increases, no cases of renal failure after donation have been noted, and negligible proteinuria among those followed long-term has been seen in this series. It is felt that living related kidney donation is justified when the relative is sincerely motivated and well informed prior to donation.

Renal transplantation. A 20-year experience in a Veterans Administration Medical Center.

Between March 1963 and December 1983, 324 renal transplants were performed in 273 veteran patients at the Veterans Administration Medical Center, Nashville, Tenn. Cadaver donors were used in 273 transplants, with an overall one-year patient survival of 72.5% and one-year functional graft survival of 50%. Twenty-four living-related transplants were performed, with an overall one-year patient survival of 89% and one-year functional graft survival of 75%. For analytical purposes the 20-year transplant experience was divided into five eras. One-year patient survival increased from 45% in era 1 to 84% in era 5, while functional graft survival increased from 45% to 70%. Death has occurred in 139 patients, with sepsis being responsible for the largest number of early deaths. Cardiovascular disease was responsible for most late deaths.

Management of aortic thrombosis secondary to umbilical artery catheters in neonates.

During the past ten years, we have surgically managed seven neonates who developed total occlusion of the distal aorta due to umbilical artery catheters. All patients experienced symptoms of congestive heart failure. Five patients presented with severe hypertension, and all of these had aortorenal involvement: three infants had aortorenal thrombosis and two infants had infrarenal aortoiliac thrombosis with suprarenal extension of thrombus. Two infants had aortoiliac thrombosis with clot confined to the infrarenal aorta. Aortic thrombosis imposes an additional severe hemodynamic insult in these already seriously ill infants. Survival in this group of patients depends upon prompt recognition of this problem, effective surgical correction, and careful perioperative management. Our experience suggests that this diagnosis should be entertained in the infant presenting suddenly with congestive heart failure, hypertension, or lower limb ischemia after umbilical artery catheterization. The diagnosis is preferably confirmed by real-time ultrasound and/or radionuclide flow scan, although aortography may sometimes be necessary. Surgical management includes early transabdominal aortotomy with thrombectomy. Prompt thrombectomy resulted in the survival of six patients. One infant died in acute renal failure. Renal function and leg perfusion is satisfactory in the remaining patients, although one child required later operative correction of renovascular hypertension. Two additional patients needed prolonged postoperative antihypertensive therapy for 14 to 34 months before this problem resolved. Long-term follow-up is necessary for managing renovascular hypertension and monitoring lower extremity perfusion.

Juxtaglomerular cell tumor of the kidney.

We describe an 11-year-old hypertensive girl who had a 5.0 cm. juxtaglomerular cell tumor. Of the 18 previously reported cases this appears to be the largest such tumor found. The benign nature of the tumor is emphasized, its clinical, radiological and microscopic appearance is illustrated, and appropriate treatment options are discussed.

Neoplasia in immunosuppressed renal transplant patients: a 20-year experience.

This review examines a 20-year experience in renal transplantation at our center to determine the effects of immunosuppression on the subsequent development of malignancies. Twenty patients had 21 malignancies from primary sites other than skin, yielding an incidence of 2.5%. There were 0.65 malignancies for each 100 cumulative patient years of immunosuppression. Suppression of the host immune response is associated with an increased incidence of malignancies.

Bilateral nephrectomy concomitantly with renal transplantation.

During a 2-year interval 206 patients underwent renal transplantation at a single center, 38 of whom underwent bilateral nephrectomy and other adjuvant operations as part of the transplant procedure. The indications for this type of procedure were reviewed, with special emphasis on the control of hypertension. The morbidity and mortality (16 per cent) in this group were compared in detail to those in patients not undergoing a concomitant adjuvant operation. The results with regard to renal function were similar to the group as a whole and the indications for appropriate patient selection are discussed.