Brown tumor in secondary hyperparathyroidism causing acute paraplegia.

The first known case of a "brown tumor" associated with secondary hyperparathyroidism causing paraplegia is described. A 69-year-old white woman with chronic renal failure due to hypertension was admitted for back pain, and while she was under observation, paraplegia developed. A complete block was demonstrated by myelography. Computed tomography confirmed a mass at the level of obstruction, and results of biopsy were consistent with "brown tumor." Neurologic symptoms were markedly improved with high-dose corticosteroids and a debulking procedure. This entity is important to recognize because prompt treatment of the hyperparathyroidism or decompression of the tumor mass by surgical means or corticosteroid administration can provide marked improvement in symptoms.

Ecthyma gangrenosum in a kidney transplant recipient with Pseudomonas septicemia.

This report describes a renal transplant recipient in whom Pseudomonas septicemia and ecthyma gangrenosum developed within days of renal transplantation. Microscopic skin sections showed perivascular bacillary invasion. Pseudomonas organisms were cultured and microscopically visualized in sections from the transplanted kidney. Although cultures from the donor kidney preservation perfusate fluid showed no growth, Pseudomonas aeruginosa was found in the recipient's urine, blood, and peritoneal fluid. The recipient's course was complicated by septic shock, cardiopulmonary arrest, coma, and extensive skin lesions; but his condition improved with appropriate antibiotic therapy, wound debridement, and an aggressive rehabilitative program. He is now a candidate for retransplantation. This is the first known case of ecthyma gangrenosum in a renal transplant recipient.

The association of pretransplant native nephrectomy with decreased renal allograft rejection.

Analysis of 2808 first and 823 second or subsequent cadaveric renal allograft recipients transplanted between June 1977 and July 1982 as part of the Southeastern Organ Procurement Foundation (SEOPF) Prospective Study was performed to determine the influence of pretransplant bilateral native nephrectomy (BNN) on graft and patient outcome. A highly significant increase in overall graft survival was associated with BNN in first transplant recipients (P less than 0.003) but not in regrafted patients. However, no increased graft survival was seen in patients receiving BNN at the time of the transplant operation. Interestingly, the improvement in graft survival associated with BNN appeared to be the result of a significant decrease in the incidence of graft loss caused by rejection--and especially accelerated acute rejection (P less than 0.007). Comparing actuarial graft survival for first graft recipients that had BNN prior to transplantation (n = 434) with those who had no nephrectomy (n = 2240) showed differences of 62% +/- 3 vs. 52% +/- 1 and 46% +/- 3 vs. 38% +/- 2 at one and three years, respectively. Analysis of first graft survival stratified for other factors known to influence outcome showed that the beneficial influence of BNN was independent of transfusion status or the number of transfusions given, use of antilymphocyte serum, pretransplant splenectomy, HLA match, or time on dialysis. The most striking increase in graft survival associated with BNN was seen in patients with evidence of presensitization as manifested by a positive panel reactive antibody (PRA) and in patients having delayed function (ATN) posttransplantation. The beneficial association of BNN was also found to be independent of the primary cause of renal failure or the specific indication leading to nephrectomy. These results suggest that patients receiving native bilateral nephrectomy prior to transplantation have a reduced incidence of graft loss from rejection by some as yet unexplained mechanism.

The timing of pretransplant transfusions and renal allograft survival.

Analysis of over 3000 cadaveric renal allograft recipients transplanted between June 1977 and June 1982 as part of the South-Eastern Organ Procurement Foundation Prospective Study was performed to determine the influence of timing of blood transfusions (BT) on patient and graft survival. Four mutually exclusive BT groups were identified for 2480 first-transplant and 655 regrafted patients studied: group 1 (n = 348, 29, respectively) received no BT; group 2 (n = 256, 29, respectively) received perioperative BT only (i.e., at the time of, or within 10 days of transplant); group 3 (n = 972, 287, respectively) received preoperative BT only (i.e., 10 or more days pretransplant); group 4 (n = 904, 310, respectively) received both preoperative and perioperative BT. For first graft recipients, actuarial graft survival for group 2 was significantly greater (P less than 0.035) than group 1 (49% vs. 41% at one year; 35% vs. 25% at 4 years), but to a lesser degree than groups 3 or 4, which were equivalent (58% at one year and 38% at 4 years). For regrafted patients, actuarial graft survival was again significantly greater (P less than 0.03) for group 2 patients, as compared with group 1 (59% vs. 29% at one year), and group 3 and 4 patients were not significantly different from each other (45% and 48% at one year, respectively) or from group 2. Interestingly, for regrafted patients who were presensitized at the time of transplant, those in group 4 (n = 94) had significantly better graft survival than group 3 (n = 111) at all time points examined (54% vs. 47% at one year, 46% vs. 22% at 3 years). In all comparisons, increases in graft survival were associated with decreased graft loss resulting from rejection, and no significant differences in patient survival were seen between any of these groups. These findings indicate that: (1) perioperative transfusions alone may have benefit in decreasing allograft rejection; (2) perioperative transfusions provide no apparent risk for patients who have already received pretransplant transfusions; and, (3) sensitized regrafted patients who receive pretransplant transfusions may gain an additional benefit from perioperative transfusions.

Multivariate analysis of risk factors in cadaver donor kidney transplantation.

Data collected prospectively on 3811 kidney transplants performed between June 1977 and July 1982 with follow-up to July 1984 by the 42 member institutions of the South-Eastern Organ Procurement foundation were analyzed to identify factors associated with graft and patient outcome in patients not receiving cyclosporine. Multivariate Cox regression analysis was used to examine the association and relative risk of 24 variables with three actuarial outcomes: overall graft failure, irreversible rejection, and patient death. Factors having no suggested association with any outcome included: recipient sex, history of pregnancy, blood group, and time on dialysis; organ preservation method, time and source; donor race; crossmatch test sensitivity; and annual center transplant rate. In decreasing order of relative risk, the factors most significantly associated with irreversible rejection were: loss of two or more prior grafts, low HLA-A,B match, lack of pretransplant blood transfusion, high (greater than 60%) pretransplant sensitization to leukocyte (HLA) antigens, and delayed graft function. Splenectomy, insulin-dependent diabetes, and antilymphocyte serum therapy provided the greatest risk of patient death. Factors such as recipient age, race, and native nephrectomy had suggested associations with outcome. By adding each center as a separate covariate in the analysis, other center-dependent factors were quantitated and found in some cases to have a highly significant association with graft and patient outcome. These results provide a basis for evaluating the potential risk of graft loss or patient death for those prospective cadaver kidney transplant recipients not being considered for cyclosporine therapy.

Identification of donor factors predisposing to high discard rates of cadaver kidneys and increased graft loss within one year posttransplantation--SEOPF 1977-1982. South-Eastern Organ Procurement Foundation.

From 1977 to 1982, the South-Eastern Organ Procurement Foundation (SEOPF) conducted a prospective study to determine the fate of all cadaver kidneys retrieved by member institutions. During the study period, 6152 kidneys were retrieved, 1264 being discarded. Donor factors predisposing to wastage included AB and A blood groups, donor age greater than 30, hospitalization greater than 3 days, serum creatinine greater than 2.0 mg%, average systolic blood pressure less than 80, last-hour urine output less than 100 ml, proteinuria, heart not beating at time of nephrectomy, and kidneys not removed en bloc. Donor factors affecting graft survival rate at one year include age, length of hospitalization, last-hour urine output, and changing serum creatinine. The data suggest that certain donor kidneys are less likely than others to be transplanted depending on donor characteristics and retrieval practices. Furthermore, some of these factors have a negative impact on long-term success when kidneys are transplanted.

The detrimental effects of delayed graft function in cadaver donor renal transplantation.

Data collected prospectively on over 3800 cadaveric renal transplants performed between June 1977 and July 1982 by the 41 member institutions of the South-Eastern Organ Procurement Foundation were analyzed to determine the influence of delayed graft function (DGF) on patient and graft outcome. Approximately 35% of first graft recipients and 47% of regrafted patients were found to have DGF, as determined by the necessity for dialysis at one week posttransplant. First-graft recipients with DGF tended to include more black recipients, patients with higher peak levels of panel reactive antibody (PRA), less use of antilymphocyte serum (ALS) posttransplant, slightly longer organ preservation times and the more frequent use of organs by ice alone. Multivariate (Cox) regression analysis considering DGF simultaneously with ten other potentially confounding variables showed a highly significant association between DGF and overall graft loss from all causes (P less than 10(-5], irreversible graft rejection (P less than 0.001) as well as patient death (P = 0.012). The differences in graft survival between first graft recipients with DGF (n = 961) versus those without DGF (n = 1769) at one and four years posttransplant were 46% +/- 2 vs. 60% +/- 1 and 28% +/- 3 vs. 40% +/- 2, respectively. The detrimental effect of DGF was highly significant irrespective of the source of donor organs or the type of preservation used. For first transplant recipients who recovered good graft function by one month following DGF (n = 564), there was a significant decrease in eventual graft survival, as compared with patients who had graft function at one month but no prior history of DGF (n = 1407; P = 0.008). However, patients with history of DGF who had good graft function at six months (n = 361) showed no significant difference in longer-term graft survival when compared with similar patients with good graft function at six months but no history of DGF (n = 912). Interestingly, first transplant recipients with DGF were found to have significantly better graft survival if they had received bilateral native nephrectomy at least one month prior to transplantation. These results indicate that delayed graft function following cadaver donor renal transplantation provides a significant risk for eventual graft and patients survival that is principally manifested during the first six months posttransplant. In addition, patients who recover graft function following DGF appear to also remain at higher risk for early graft loss, while pretransplant bilateral native nephrectomy may afford some protection against the detrimental effects of DGF.

The influence of pretransplant transfusions, using different blood products, on patient sensitization and renal allograft survival.

An analysis of data collected during the South Eastern Organ Procurement Foundation (SEOPF) Prospective Study from 1977-1982 was performed to identify the relative effects of different blood products on patient sensitization and graft survival in cadaveric donor renal transplant recipients. More than 2700 primary and 800 regrafted patients from 40 transplant centers were included in this study. A significant increase in actuarial graft survival was seen in primary recipients who had pretransplant transfusions with only frozen blood (P less than 0.003), washed blood (P less than 0.0005), packed blood (P less than 0.0001), or any combination of blood products (P less than 0.002) as compared with those who received no transfusions. No blood product was found to provide a significantly greater increase in graft survival than any other blood product. Likewise, regrafted patients had significant and equivalent increases in graft survival associated with each type of blood product examined. The increased graft survival associated with each blood product was the result of decreased graft rejection, and not apparently related to other differences among patients receiving different types of blood. Furthermore, the type of blood used in pretransplant transfusions did not significantly influence the degree of patient sensitization for first-graft recipients, although regrafted recipients who received packed blood or a combination of blood products showed a slightly greater degree of sensitization than those who received only frozen or washed blood. First-graft recipients given packed or mixed blood had a small, statistically insignificant increase of hepatitis B virus (HBV) antigenemia, compared with those receiving frozen, washed, or no blood. Regrafted patients given any type of transfusion had a 3-4-fold increased incidence of HBV antigenemia as compared with nontransfused patients, but this difference also was statistically not significant. These findings suggest that the benefits of increased graft survival and the risks of sensitization or HBV infection associated with pretransplant transfusions are not significantly affected by the type of blood used.

Cadaver renal transplantation ignoring peak-reactive sera in patients with markedly decreasing pretransplant sensitization.

A review of more than 3000 cadaver donor renal allograft recipients transplanted between June 1977 and July 1982 as part of the South-Eastern Organ Procurement Foundation (SEOPF) Prospective Study was performed to identify patients who received a transplant following a significant decrease in pretransplant sensitization as measured by the percentage of panel-reactive antibody (PRA). Such patients were identified as having had a most reactive (historical peak sera) PRA level at least 40 percentage points higher than their last sample tested prior to transplant (current sera). Additional data were obtained on 157 of these patients, who also had no history of pretransplant immunosuppression and had a negative pretransplant crossmatch with current sera. Data included the dates of pretransplant sera samples, the specific techniques used for each serum sample that was crossmatched or screened for PRA, and the serological results. The population studied included 17 of 87 first-transplant recipients and 17 of 70 regrafted recipients whose pretransplant crossmatches with peak sera were positive or not done. These subgroups showed no decrease in graft or patient survival compared with cohorts (70/87 first-transplant recipients and 53/70 regrafted recipients) for whom peak sera crossmatching was performed with negative results. Additional stratification for the techniques used in crossmatching and screening, as well as the interval between peak and current PRA levels, showed no significant associations with eventual graft or patient outcome. These results suggest that crossmatch testing using peak sera may not be important in predicting eventual graft or patient outcome for patients with a marked decrease in PRA prior to transplantation and a negative crossmatch with current sera.

Influence of changes in pretransplant sensitization on patient and graft survival in cadaver renal transplantation.

Analysis of 2778 primary and 606 regrafted cadaveric donor renal allograft recipients transplanted between June 1977 and July 1982 as part of the South-Eastern Organ Procurement Foundation (SEOPF) Prospective Study was performed to determine the influence of changes in presensitization on graft and patient outcome. Four mutually exclusive groups of patients were identified based on the relative difference in the percentage of panel-reactive antibody (PRA) from highest ever (peak) to most recent (current) pretransplant levels as follows: group 1 (unsensitized): peak = current PRA = 0; group 2 (rising or stable PRA): (peak = current PRA) greater than 0; group 3 (small decrease): (peak - current PRA) = 1-40%;) and group 4 (large decrease): (peak - current PRA) greater than 40%. First-transplant recipients in group 4 had significantly higher mortality when compared with groups 1-3 (P less than 0.002). This decrease in patient survival was evident at 6 months (81% +/- 4 vs 91% +/- 1) and persisted to three years (68% +/- 8 vs 78% +/- 2), and it was associated with a significant (P less than 0.037) increase in death from infectious causes. This finding was even more striking when only transfused recipients were considered: at three years the difference in patient survival was 63% +/- 11 vs. 77% +/- 2. In addition, transfused patients with a decrease in pretransplant PRA of greater than 40% had significantly lower overall graft survival (P less than 0.02) and a higher incidence of irreversible graft rejection (50% +/- 8 vs 33% +/- 1 at two years). For regrafted recipients, there were no differences in patient survival among groups, but those in group 4 had significantly lower graft survival (P less than 0.0033) than groups 1-3. These findings suggest that a substantial decrease in PRA prior to transplant does not necessarily indicate a decrease in potential donor alloreactivity, and in first-graft recipients it may reflect an increased susceptibility to life-threatening infections following transplantation.

Transplantation for polycystic kidney disease.

During the 4-year period from June 1977 to May 1981, a total of 108 patients with polycystic kidney disease and 2440 nonpolycystic patients received cadaver renal allografts in the Southeastern Organ Procurement Foundation (SEOPF) Prospective Study. There were no significant differences between the groups with and without polycystic disease in terms of recipient blood group, history of splenectomy, or preformed antibody status. As a group, transplanted polycystic patients underwent native nephrectomy more often, had a better HLA match, received less antilymphocyte serum (ALS), and were slightly older than nonpolycystic patients. Although proportionately fewer polycystic patients received pretransplant transfusions than nonpolycystic patients (P = .002), transfusion was associated with a significant increase in graft survival in the polycystic group (P less than .05), as well as in the nonpolycystic group (P less than .0001). Gene frequency analysis showed no HLA-A, or -B antigen linkage with polycystic disease. No significant differences existed between the polycystic and nonpolycystic groups in terms of overall graft and patient survival. However, transplanted polycystic patients died more frequently from bacterial sepsis (P less than .05), especially from gram-positive organisms (P = .01). Pretransplant bilateral nephrectomy did not affect the incidence of sepsis. However, following graft failure, patients with bilateral native nephrectomy had a greater incidence of severe anemia (50% versus 39%) and death (58% versus 25%; P less than .05) than those with unilateral nephrectomy or no nephrectomy. Treatment with ALS did not significantly improve graft survival in those with polycystic disease. A strong positive correlation was found between patient death and treatment with ALS only in the polycystic group (P less than .01). These findings indicate that the use of pretransplant bilateral native nephrectomy and posttransplant ALS should be judicious in the polycystic patient because they may be associated with increased morbidity and mortality.

Adverse effects of meglumine diatrizoate on renal function in the early post-transplant period.

Thirty-four renal transplant recipients received drip infusion urograms from 2-24 days post-transplantation. Twenty-two patients exhibited changes in renal function within 1-4 days of the urogram that were indistinguishable from allograft rejection: a tender, swollen kidney, elevation of serum creatinine, oliguria, decreased urine sodium concentration, weight gain, and hypertension. Two patients developed acute tubular necrosis and required hemodialysis, but renal function in the remaining 20 patients improved after therapy for "graft rejection" with i.v. methyprednisolone sodium succinnate. Kidneys from older-age donors that were functioning suboptimally and kidneys which exhibited subsequent clinical allograft rejection were more at risk for contrast media toxicity. This suggests that occult vascular lesions may have been present in the allograft which were exacerbated when exposed to the irritant vascular effects of contrast media, producing a mild, reversible toxic nephritis. However, several kidneys with normal function and several kidneys which never exhibited rejection activity were also adversely affected by exposure to contrast media. It appears these agents should be used cautiously, if at all, in the early post-transplant period.

The effect of HLA-A, -B matching on cadaver renal allograft rejection comparing public and private specificities.

Data collected prospectively on 3811 cadaver renal transplants performed between June 1977 and July 1982 by the 42 member institutions of the South-Eastern Organ Procurement Foundation (SEOPF) were analyzed to determine whether donor-recipient compatibility based on public rather than private HLA-A,-B specificities influenced the beneficial effect of HLA matching on outcome. HLA compatibility was calculated considering match and mismatch based on common private or various public (crossreactive group, [CREG]) specificities. Donor-recipient compatibility using certain CREG assignments provided an equivalent means of stratifying graft outcome by the degree of HLA-A,-B match or mismatch, and other CREGs assignments did not. Multivariate Cox regression analysis of donor-recipient compatibility based on certain public antigens showed as high an association (P less than 10(-5) between good matching and decreased graft rejection as did matching for private antigens alone. Patient stratification by HLA match provided a stronger association with graft outcome than by HLA mismatch, irrespective of whether private or public antigens were considered. The likelihood of finding a better match was significantly increased using CREG assignments, and patients with at least one matched private antigen had equivalent or better graft survival when additional public antigens were matched. These findings indicate that with conventional immunosuppressive therapy: (1) matching of private or public HLA-A,-B antigens plays a highly significant role in decreasing renal allograft rejection; (2) matching based on certain public antigens can provide the same or a better association with outcome as private antigens; and (3) the association (crossreactivity) of various HLA specificities can be defined on a functional basis in terms of graft survival.

Method of preservation is not a determinant of graft outcome in kidneys transplanted by Southeastern Organ Procurement Foundation Institutions.

We report the observation that the major sources of variation in cadaver renal allograft survival rates are not related to the technique of donor organ preservation but are related solely to other factors including pretransplant blood transfusion of the recipient, antilymphocyte serum (ALS) treatment of the recipient, and high HLA match. In contrast to prior studies which used univariate methods to analyze similar data, our analysis shows that it is imperative that comparisons of different methods of cadaver preservation must include adjustments for the effects of pretransplant blood transfusions, antilymphocyte serum, and HLA match.

Assessment of prognostic factors and projection of outcomes in renal transplantation.

Analysis of data on renal transplantation collected in two large multicenter observational studies resulted in the concordant identification of five factors that correlated highly and at a substantial level of statistical significance with the outcome of unrelated cadaveric donor transplantation (i.e., they were associated with differences in one-year graft survivals of 0.07-0.21 and P values less than 0.05). These factors were: blood transfusions prior to the transplant, race of the recipient (white or black), prior failure in transplantation, level of sensitization to lymphocyte alloantigens, and diabetes as the cause of end-stage renal failure. Multivariate analysis with a mathematical survival model confirmed the importance and independence of these prognostic factors. Matching of HLA antigens appeared to be beneficial in both studies, but failed to attain high statistical significance in one. Systematic differences in the use of pretransplant splenectomy and, probably, in the nature of the antilymphocyte serum or globulin led to discordance in assessment of the importance of these factors in the two studies. Although advanced age (greater than 45 years) of the recipient was associated with reduced graft survival in both studies, analysis by means of the model failed to detect a significant correlation between the recipient's age and the outcome in one of the studies because the relation was not monotonic. In an illustration of their utility in the detailed assessment of performance, the prognostic factors were found to substantially account for the markedly superior results at one center and partly for lower graft survivals at another. These prognostic factors may be used to predict probable outcomes for populations and for individual patients subjected to particular arrays of conditioning strategies.

Immune injury from organ preservation. A potential cause of hyperacute rejection in human cadaver kidney transplantation.

Two pairs of plasma-perfused human cadaver kidneys were rejected in a hyperacute manner by recipients who had not previously received a transplant. Crossmatches between recipient sera and donor lymphocytes were negative in all cases. A fifth kidney was plasma-perfused but not transplanted because the perfusate was shown to be cytotoxic to donor lymphocytes. IgM and complement, but not IgG, were demonstrated in these kidneys by immunofluorescent microscopy and confirmed by further immunological studies. The IgM was broadly reactive against multiple HL-A specificities and was present in 11 percent of sera from normal, healthy male donors. It appears from our studies that cytotoxic IgM may be present in homologous plasma and cause immune injury to the kidney during ex vivo pulsatile preservation. This may be responsible for some cases of otherwise unexplained accelerated allograft rejection.

An appraisal of en bloc resection of peripheral bronchogenic carcinoma involving the thoracic wall.

Thirty-two patients with peripheral bronchogenic neoplasms adherent to the chest wall underwent en bloc pulmonary and thoracic wall resections. Presenting symptoms were thoracic wall pain (75 percent), hemoptysis (12.5 percent), and cough with weight loss (12.5 percent). Patients were selected for surgical resection only after a search for metastatic disease, including mediastinoscopy, showed negative results. A standard posterolateral thoracotomy incision was used which did not require skeletal reconstruction or prosthetic material for closure. There were nine major postoperative complications (28.8 percent), principally respiratory, and one operative death (3.1 percent). The five-year actuarial survival was 35 percent. None of the patients with regional lymph node involvement or positive chest wall margins lived more than two years after surgery. Preoperative irradiation performed in 12 patients (37.5 percent) improved operability, but did not significantly alter survival. These results indicate that patients with peripheral bronchogenic carcinoma involving the thoracic wall may be successfully managed with en bloc pulmonary and chest wall resection, particularly if surgery is performed in the early stage of the disease.

Arterial injury during perfusion preservation: a possible cause of posttransplantation renal artery stenosis.

To evaluate the effect of perfusion preservation upon renal arteries, 10 sets of porcine kidneys were removed en bloc and flushed in iced Sacks' solution via an aortic cannula. Preservation at 4 degrees C was by ice storage without perfusion (10 kidneys), perfusion with cannulation of the aortic segment (five kidneys), or perfusion with direct cannulation of the renal artery (five kidneys). After 48 to 72 hours the renal arteries and their primary branches were examined histologically. No intimal changes were evident by light microscopy. By scanning electron microscopy the endothelium of all renal arteries preserved by ice storage or aortic perfusion remained intact with only occasional deposits of particulate matter. By contrast, three distinct lesions appeared in all arteries subjected to direct cannulation: (1) full-thickness crushing at the site of the securing ligature, (2) intimal flattening at the site of contact with the cannula, and (3) marked disruption of intimal architecture extending several millimeters beyond the cannula tip. The latter injury, presumably caused by turbulent flow, is not apparent to the unaided eye. If this abnormal intima is not adequately excised at the time of transplantation, fibrin and platelet deposition may lead to fibrosis and localized arterial stenosis. The injury can be avoided by ice storage or by indirect perfusion via an aortic cannula.

Diagnosis and management of retroperitoneal hematomas after femoral vein cannulation for hemodialysis.

Six patients were identified who suffered retroperitoneal hemorrhage during or after hemodialysis via a femoral vein approach. Hypotension developing during dialysis or lower quadrant abdominal pain was the common presenting symptom. All patients had decreasing hematocrits and five of the six patients required blood transfusions. The method of diagnosis was clinical, with plain abdominal x-ray examination and cystography being the most helpful adjuncts. All patients were successfully treated with volume resuscitation and removal of the femoral vein catheters; none required operative intervention or suffered adverse late effects. Femoral vein dialysis is useful for uremic patients without other peripheral vascular access options, and its associated morbidity may be minimized provided complications are recognized and promptly treated.

Transplantation in patients with a history of renal cell carcinoma: long-term results and clinical considerations.

We report four cases of renal transplantation after prior incidental removal of renal cell carcinomas. Follow-up periods ranged from 21 months to 8 years. Our experience provides the first long-term follow-up of such cases and indicates that the overall prognosis is favorable when asymptomatic renal adenocarcinomas are removed prior to renal transplantation. The period between nephrectomy and renal transplantation ranged from 8 hours to 30 months. Three patients had prolonged tumor-free survival, and one died from a widely disseminated second adenocarcinoma 21 months after transplantation.