Complications of laparoscopic gastric banding in renal transplant recipients: a case study.

As bariatric surgery becomes more popular, the number of renal transplant recipients who undergo weight loss surgery will continue to grow. This population presents unique challenges because of increased infection risks, tendency to posttransplant weight gain, and inferior tissue-healing properties. We present two cases of renal transplant recipients who experienced the complications of band erosion and band migration after laparoscopic gastric banding, and we discuss the special considerations that apply to this patient population.

Relationship of renal transplantation to hypertension in end-stage renal failure.

The relationship of renal transplantation to new onset or persistence of previously established hypertension was analyzed in 164 transplant recipients in whom the renal allograft functioned for six months or longer. Of the 164, thirty-seven (23%) had normal blood pressure and 127 (77%) were hypertensive prior to transplantation. Following transplantation 83 patients (51%) were normotensive; high blood pressure was found in 81 (49%). Posttransplant hypertension could not be correlated with the recipient's original renal disease, age, sex, renal donor source, donor age, or maintenance dose of prednisone. More normotensive paients had undergone prior binephrectomy when compared with the hypertensive group (P less than .05). Mean serum creatinine levels was higher (2.0 mg/dl) in hypertensives than in normotensives (1.54 mg/dl) (P greater than .05). Selective renal veins' renin measurements in patients with severe hypertension were not helpful in predicting the beneficial effects of either bilateral nephrectomy or surgical correction of transplant renal artery stenosis.

Adverse impact of hypertension on diabetic recipients of transplanted kidneys.

The effect of hypertension on patient and allograft survival in 60 diabetic recipients of transplanted kidneys was assessed by retrospective chart analysis. Hypertension was present in 81% of recipients. Of eight of these patients who became normotensive after transplantation, all had functioning allografts and one died. By contrast, persistent hypertension after transplantation was associated with a higher mortality rate (25 of 54, 48%) and loss of kidney graft function (19 of 54, 35%). At a mean of 21 months after transplantation, living hypertensive diabetic recipients had worse renal function (mean serum creatinine of 3.1 mg/dl) than did nonhypertensive recipients (mean serum creatinine of 1.6 mg/dl). It is concluded that hypertension is a significant risk factor for diabetic patients and kidneys after transplantation.

Listeria monocytogenes: brain abscess or meningoencephalitis?

A brain abscess caused by Listeria monocytogenes developed in an immunosuppressed renal transplant patient. Meningitis and meningoencephalitis from this organism were encountered in three other renal transplant recipients at this medical center during the past 4 years. Focal neurologic deficits occurred in patients with either Listeria abscess or meningoencephalitis. Computerized tomography was a rapid aid to the diagnosis of abscess. Immunosuppression has increased the incidence of central nervous system Listeria infections, but ampicillin still provides effective treatment, even when immunosuppressive therapy is continued. Limited experience with Listeria brain abscess suggests that surgical intervention improves the prognosis.

Renal transplantation in multiple myeloma. Case report and review of the literature.

A patient with end-stage renal disease and known benign monoclonal gammopathy underwent kidney transplantation at Westchester County Medical Center, Valhalla, NY. After surgery, during routine follow-up, the patient had laboratory evidence of frank multiple myeloma. However, she did not show any clinical signs or symptoms of the disease. Four years later, the patient is asymptomatic and continues to have stable renal function. As a result of our experience, and that of others, we support transplantation as a viable option for patients with multiple myeloma.

Strategies for optimizing growth in children with kidney transplants.

Children with a well-functioning graft continue to show growth retardation even with low-dose prednisone. We have attempted to utilize the steroid-sparing effect of cyclosporine by discontinuing prednisone after graft stabilization. Since 1983, 53 children have received cyclosporine as primary immunosuppressant for renal graft maintenance. The children, aged 6 months to 18 years, received 60 transplants. One-year and four-year patient survival for cadaveric transplants was 91% and 91%, compared with 96% and 96% for living related transplants. One-year and four-year graft survivals were 82% and 65% for cadaveric transplants (n = 25), compared with 91% and 63% for living related transplants (n = 35). Of 53 patients, 23 were able to discontinue prednisone and be maintained on monodrug cyclosporine therapy, and 21 of the 53 patients had growth hormone measured using L-dopa stimulation. In patients receiving more than 5 mg of prednisone daily, growth hormone levels were lower than normal (less than 10 ng/ml). Of 15 patients who had discontinued prednisone for more than 6 months, 13 showed accelerated growth by improvement in their standard deviation scores. In 4 pubescent children with growth retardation and need for maintenance prednisone, accelerated growth occurred following growth hormone administration for 3-6 months. Based on these data we suggest that (1) discontinuation of even very small doses of prednisone may be essential for normalizing growth hormone response to L-dopa and (2) further studies are needed to exploit the growth stimulation effect of recombinant growth hormone in transplanted children.

Diabetes mellitus after renal transplantation in the cyclosporine era--an analysis of risk factors.

Despite mounting experimental evidence that cyclosporine inhibits pancreatic islet cell function, clinical data on posttransplant diabetes mellitus (PTDM) in renal allograft recipients in the cyclosporine era are scarce. Between June 1983 and December 1988, 39 of 337 (11.6%) cyclosporine-treated adult renal transplant recipient whose grafts survived longer than 1 year developed PTDM. Of these, 43.6% and 74.4% were diagnosed by 3 and 12 months posttransplant, respectively, and 51.3% were insulin-dependent. Incidence of PTDM was highest in blacks (19.8%) and Hispanics (21.3%) and in those with HLA-A 30 and Bw 42 antigens. Older recipients and those that received cadaveric kidneys were more likely to develop diabetes than those who received living related allografts (14% vs. 5.3%, P less than 0.05). The rate of PTDM appeared to be independent of the type of induction, immunosuppressant therapy, incidence of rejection, total steroid and cyclosporine dose, percentage of body weight gain in the first posttransplant year, and serum creatinine concentration. Actuarial 5-year, decaying from 100% at 1 year, patient and graft survival rates were 87% and 70%, respectively, in the PTDM group compared with 93% and 90%, respectively, in controls. Causes of graft failure among the diabetics included chronic rejection (6), patient death (3), noncompliance with immunosuppressants (2), and sepsis (1). The incidence of infectious complications was significantly higher in the PTDM group compared with the control group (53% vs. 16%, P less than 0.05), with all 5 deaths among the diabetics being sepsis-related.

Influence of cadaver donor age on the success of kidney transplants.

To investigate the impact of donor age on the outcome of renal transplants, a retrospective analysis of 440 consecutive cadaver donor kidney transplants were performed by dividing the transplants into six groups, according to the decade of donor age. These groups were comparable with regard to recipient age, sex, race, and HLA matching grade, while the pediatric group received kidneys preferentially from the first and second decade donors. Although cadaver donor age, between 11 and 50 years, did not appear to influence the result of kidney transplants, the kidneys retrieved from the first and sixth or higher decades of donors fared significantly worse. Improved criteria for the evaluation, selection, and management of cadaver donors of extreme ages is needed to achieve a satisfactory result.

Prolonged epicardial mapping in myocardial infarction: the effects of propranolol and intra-aortic balloon pumping following coronary artery occlusion.

A methods of prolonged epicardial surface mapping of myocardial infarction by serial epicardial ECG's is described. The progression of infarction following coronary artery ligation in dogs was monitored over a 4 day period and the early and late changes in the configuration of the epicardial ECG's associated with the underlying myocardial injury were defined. The determination of the infarct size by surface mapping in vivo correlated accurately with the final infarct size determined by dehydrogenase staining in vitro. Treatment with propranolol resulted in a significant reduction in the infarct size. Treatment with intra-aortic balloon pumping did not alter the size of the myocardial infarction induced in this experimental model.

A new vascular access for hemodialysis: the arterial jump graft.

In seven patients in whom conventional vascular access for maintenance hemodialysis was not possible, a new access in the form of a femoropopliteal jump graft was employed. A follow-up of 3 months to 3 years (92 patient months) and an experience of more than 1,000 dialysis treatments have shown it to be a stable and satisfactory access.

Results of renal transplantation using pediatric cadaver donors.

In order to determine the results of transplantation using pediatric cadaver donors, a retrospective analysis of a series of 502 renal transplant recipients was carried out. Methods of procurement, preservation, recipient selection, and immunosuppressive regimen were similar for all patients. Sixty-five recipients were approximately equally divided into three groups whose donors were younger than 5 years of age, 6 to 10 years old, and 11 to 15 years. These three groups then were compared with each other and to a randomly selected representative group of recipients whose donors were adults (16 years or older) for the following parameters: actuarial graft and patient survival, causes of graft failure and patient death, level of serum creatinine in currently functioning grafts, and recipient age. There were no statistically significant differences between groups for any parameter except that the mean age of recipients was approximately 16 years for the donors up to 5 years of age and was between 31 and 36 years for the other donor age groups (P = 0.01). These results support the contention that brain-dead pediatric patients of any age should be considered to be potential cadaveric kidney donors. Exclusion of these patients is very wasteful and also is unnecessary since results of transplantation equal to those obtained with adult donors can be expected. Technical graft failures should not be more frequent than with adult kidneys, and there is no need to modify the basic surgical technique for small kidneys in order to achieve this.

Vascular complications in human renal transplantation.

There were 13 arterial complications in 202 transplants done in 162 patients, an incidence of 6.5 percent. Renal arterial stenosis was demonstrated by angiogram in six kidneys; four were reconstructed successfully. Four renal arterial occlusions were found in delayed rejected kidneys. Of three arterial dehiscences secondary to infection, all led to graftectomy. One of these patients died 56 days later due to infectious hepatitis, and one underwent a successful retransplant. One patient had an occluded iliac artery which was repaired successfully. A single venous complication occurred in one patient.

Cavitary Legionnaires' pneumonia: nosocomial infection in renal transplant recipients.

Cavitation is an unusual manifestation of legionnaires' pneumonia. Mortality rates range from 24 to 58 percent with effective therapy. Antibiotic therapy is not standardized and is largely based on anecdotal reports. This report has described nosocomially acquired cavitary legionnaires' pneumonia in five renal transplant recipients. The diagnosis was made by seroconversion and immunofluorescent staining of lung tissue or transtracheal aspirates. Frequently seen associated symptoms were not present. All patients were successfully treated with 2 to 4 g of erythromycin for at least 4 weeks.

Blood access.

Blood access is the most important determinant for the continued well-being of an end-stage renal failure patient, maintained on hemodialysis. From the variety of angioaccess techniques available today, the choice of one most suitable for a patient, applied at the appropriate time with an exacting technique may liberate the patient from incessant fear of loss of his "life line". Quinton-Schribner shunt as a prototype of external prosthetic angioaccess devices made life on the artificial kidney possible, but repeated thrombosis, inevitable infection, limitations of activity and threat of accidental dislodgement have severly restricted its usefulness. The internal arteriovenous fistula and its several modifications have almost completely supplanted the use of external prosthetic devices. When the procedure of choice, a direct arterio-venous fistula, is not applicable, an interposed graft of biologic prosthetic origin may be employed. Percutaneous femoral vein catheterization and veno-venous dialysis is an acceptable, indeed a valuable "stop gap" measure.

The use of captopril to control hypertension in post-transplant renal artery stenosis.

Captopril is a new orally active angiotensin converting enzyme inhibitor that is useful for the treatment of hypertension. Prior reports have cautioned against its use for the control of blood pressure in patients with transplant renal artery stenosis since it caused a reversible renal failure. We describe a four year old child with radiographically proven transplant renal artery stenosis and severe hypertension that was safely managed with long-term administration of captopril. This case highlights the continued therapeutic role of this drug in the treatment of post-transplant hypertension, provided one carefully monitors the renal function in such patients.

In vivo potentiation of cyclosporine immunosuppression by calcium antagonists.

We have shown that the addition of verapamil, a calcium channel blocking agent, or trifluoperazine, a phenothiazine, to a regiment using the immunosuppressive agent Cs significantly enhances heterotopic cardiac allograft survival in an ACI to Lewis transplant model. This work verifies previous in vitro work from our laboratory and offers a potential therapeutic strategy to decrease the dose of Cs needed for effective immunosuppression while perhaps lessening its dose-related side effects.

Pediatric and adult renal transplants: a comparative study.

In order to compare the results of renal transplantation in pediatric and adult recipients, a retrospective analysis of first transplants done at a single institution over a 6-yr period was carried out. The study included 21 pediatric and 196 adult recipients of cadaveric grafts, and 18 pediatric and 156 adult recipients of living related grafts. Pediatric and adult recipient groups were shown to be similar to each other with respect to donor-recipient HLA antigen matching and to causes of graft failure and patient mortality. Actuarial graft and patient survival data for pediatric recipients was found to be better than for the corresponding adult recipient groups, although the differences were not statistically significant. When clinical results, technical problems, and psychosocial adaptation are considered critically, transplantation is clearly preferable to both hemodialysis and to no treatment for pediatric patients with end stage renal disease (ESRD). There is a considerable discrepancy between the estimated incidence of ESRD in children and the number of children being tranplanted for this disease. Many patients are, therefore, receiving less than optimum treatment. Efforts to correct this discrepancy are in order.

Successful renal transplantation in infancy.

This infant's post renal transplantation course, representing apparently the smallest long term survivor, illustrates that neither age nor size are contraindications to successful renal transplantation in infants with end stage renal failure. Additional experience with the transplantation of a single kidney into a 1-yr-old baby weighing 4650 gm with congenital bilateral renal hypoplasia has also been successful with a 3-mo follow-up. Both cases demonstrate that single or double renal transplantation in infants is feasible and should be considered when indicated.