Improved management of congestive heart failure. Use of continuous ambulatory peritoneal dialysis.

Four patients suffering from end-stage congestive heart failure (CHF) refractory to conventional medical treatment were treated with continuous ambulatory peritoneal dialysis (CAPD) for one to 21 months. All four patients improved from class IV CHF to class II, as defined by the New York Heart Association, and experienced a definite improvement in their sense of well-being. Three patients, women between 42 and 59 years of age with contraindications for heart transplantation, were all professionally rehabilitated. One 21-year-old patient received CAPD until he underwent a successful orthotopic heart transplantation. We thus propose CAPD as an effective treatment for end-stage CHF refractory to conventional medical treatment.

Neopterin as a new biochemical marker for diagnosis of allograft rejection. Experience based upon evaluation of 100 consecutive cases.

The use of daily urinary neopterin evaluation to detect immunological complications has been tested in 96 consecutive cadaveric kidney recipients, three liver recipients, and one pancreas recipient. In 29 of these patients an immunologically uncomplicated posttransplant course was associated with stable or low neopterin levels, or both. In only 5% of daily determinations on these patients were increasing or high neopterin levels seen. On the other hand, major immunological complications, such as acute rejection episodes (38 cases), viral infections (17 cases), or both problems (8 cases), were preceded by increasing or high neopterin levels or both--on the average by one day. Withdrawal of cyclosporine was also found to be followed by increase of urinary neopterin levels. Neopterin evaluation enabled reliable and accurate prediction of immunological complications in 95% of patients with acute rejections and in 100% of patients with viral infections. It thus appears that daily assessment of urinary neopterin levels represents a useful tool for biochemical detection of immunological complications in allograft recipients.

Posttransplant neopterin excretion in renal allograft recipients--a reliable diagnostic aid for acute rejection and a predictive marker of long-term graft survival.

During the immediate posttransplant period, daily measurements of urinary neopterin, which is produced by stimulated macrophages, were evaluated in 294 consecutive recipients of renal allografts for their diagnostic value in acute graft rejection. The ability of mean and peak neopterin excretion values to predict long-term graft survival was analyzed on the basis of an eight-year follow-up. Immunosuppressive therapy (cyclosporine +/- prednisone versus azathioprine + prednisone) and initial nonfunction did not influence neopterin excretion. In patients with rejection episodes and in those with infections, neopterin levels were significantly increased. Diagnostic sensitivity and specificity with regard to rejection diagnosis were assessed for different levels of neopterin. By statistical analysis, a significant association between increased neopterin and higher risk of rejection was found, which was particularly pronounced in patients receiving cyclosporine. Increase in neopterin excretion preceded clinical rejection diagnosis by up to four days. Peak neopterin values above 800 mumols/mol urinary creatinine observed during the posttransplant period, were associated with significantly poorer graft survival. A multivariate analysis showed that peak neopterin levels, age of patients, and early posttransplant presence/absence of acute rejection were significant and independent joint predictors for long-term graft survival. Measurement of neopterin can be of help as an additional marker in early diagnosis of renal allograft rejection, and high neopterin values during the initial posttransplant period are associated with poorer long-term graft survival.

Evaluation of spontaneous lymphocyte proliferation by single cell autoradiography in human allograft recipients.

Spontaneous lymphocyte proliferation was studied in 22 patients receiving cadaveric renal transplants before and at various times after grafting. Prophylactic immunosuppression consisted of CyA and prednisone. Spontaneous lymphocyte proliferation was evaluated in a total of 500 single cell autoradiographs after short term in vitro incubation with [3H]TdR. In 13 patients without clinical problems a transitory increase of lymphocyte labeling indices to approximately five times the pretransplant levels was observed. The failure to detect such increments in two patients receiving optimally matched grafts suggested that this early proliferative lymphocyte peak might be caused by in vivo recognition of major histocompatibility antigens. Much higher labeling indices were detected in close temporary association with acute cellular rejection (4 cases), severe infections and withdrawal of CyA (3 cases) and venous thrombosis (1 case). Only moderately elevated numbers of spontaneously proliferating lymphocytes were seen in one patient with a reversible vascular rejection episode. It appears that assessment of spontaneous lymphocyte proliferation is capable of discriminating on a quantitative level between patients with and without clinical problems such as acute cellular rejection and infection.

Beta 2-microglobulin: a prognostic parameter for graft survival after renal transplantation.

The determination of beta 2-microglobulin has recently been proposed as a promising diagnostic method to monitor the state of renal allografts. Elevated levels of beta 2MG in the serum and/or urine allow the substantiation of the diagnosis of an acute graft rejection and are helpful in distinguishing acute tubular necrosis from a rejection reaction. In this paper, the usefulness of beta 2MG serum levels is evaluated, not only during the immediate post-operation phase but also for the long-term prognosis of renal allografts. The immunosuppression treatment included methylprednisolone and azathioprine in all the presented patients. The data indicate that a rapid normalization of beta 2MGSL within 6 days, even if the decrease is interrupted by re-elevation due to acute rejection episodes or inflammatory diseases, represents a good long-term prognosis for kidney allografts.

Follow-up studies on proliferative T cell responses in cadaveric kidney graft recipients under combined immunosuppressive treatment with cyclosporine and prednisone.

In 5 recipients of cadaveric renal allografts, we tested the influence of prophylactic immunosuppression with cyclosporine (Cy A) and low dose prednisone on in vitro proliferative T cell responses, T-helper/T-suppressor cell ratios and spontaneous- or lectin-induced unspecific suppressor cell activity and on serum mediated inhibition of proliferative T cell responses. Results revealed a reduction of the overall proliferative T cell responsiveness, which was particularly seen in cultures supplemented with autologous serum and was maximally expressed after approximately 30 days of treatment. This impaired proliferative capacity was neither accompanied by shifts of the T-helper/T-suppressor ratios nor by alterations of spontaneous- or lectin-induced suppressor activity. The capacity of patients' plasma to inhibit lymphocyte proliferation was also tested. Results indicated that almost every plasma of Cy A patients was capable of inhibiting mixed lymphocyte culture (MLC) responses. The inhibitory capacities of these plasma, however, were not directly correlated with their Cy A content.

Exogenous IL2 partially reverts CML non-reactivity acquired during prophylactic immunosuppression with cyclosporin A of human allograft recipients.

Proliferative and cytolytic lymphocyte responses and the influence of exogenous interleukin 2 (IL2) on cell-mediated lympholysis (CML) reactivity were evaluated in 12 allograft recipients. Responses were induced by mitogenic lectins or by donor and third-party cells. Patients were tested immediately before transplantation (Tx) and one and three months after grafting. Prophylactic immunosuppression consisted of Cyclosporin A (CyA) and low-dose prednisone (P). Analysis of post transplant cells revealed a reduced overall proliferative T cell responsiveness induced by both alloantigens and mitogenic lectins. No evidence for donor-specific reduction of MLC responses was seen. Overall CML reactivity of post-Tx lymphocytes was also impaired. This was accompanied by donor-specific CML non-reactivity in six of seven patients with quiescent grafts. In these patients, the cytolytic potential against donor cells could be restored when maximal T cell help via exogenous IL2 was provided.

[Percutaneous sonographic angioplasty. Initial experimental results]. / Perkutane sonographische Angioplastie. Erste experimentelle Ergebnisse.

Aim of the present study was to examine in vitro the effects of a new ultrasound catheter system on atherosclerotic and normal vessels before employing the system in humans. 141 attempts were made on 32 vascular preparations obtained at autopsy. The vessels were opened longitudinally within 24 hours of death, dilated with gelatine and were then "treated" in a waterbath using varying degrees of pressure, angle of incidence, sound intensity and duration of sound. Macroscopic and histological examinations of the preparation showed no morphological change in normal vessels except evidence of pressure by the catheter. In particular, there were no perforations of the vessel wall. In atherosclerotic segments there was significant reduction in the size of plaques following treatment.

[Experiences with continuous ambulatory peritoneal dialysis (CAPD) at the University Clinic for Internal Medicine in Innsbruck]. / Erfahrungen mit kontinuierlicher ambulanter Peritonealdialyse (CAPD) an der Universitätsklinik für Innere Medizin in Innsbruck.

First described by Popovich et al. in 1978 [7], and modified by Oreopoulos et al. [6], CAPD is accepted as a simple technique which offers chronic dialysis to patients who are either unsuitable for, or noncompliant with, haemodialysis (HD). The technique of CAPD is based on the theoretical basis which predicted that adequate dialysis could be obtained if 10 litres of dialysis fluid per day are allowed to equilibrate with body fluids [5]. In practice, 2 litres of peritoneal dialysis solution are present in the peritoneal cavity, continuously, except for the periods when the patient exchanges the dialysate for fresh solution via a permanent peritoneal catheter [3]. The patient is ambulant and independent of hospital and machine. In our experience, with good technology and careful patient selection CAPD is now a well-established procedure and the preferred method of dialysis for some patients.

[Experiences with kidney transplantation in elderly patients]. / Erfahrungen mit der Nierentransplantation bei älteren Patienten.

Despite a significant increase in the number of elderly patients with end stage renal disease, these patients still represent a minority of renal transplant recipients in many countries. Roughly the recipients in the present study were older than 50 years of age. Infection was a more common complication in these patients than in the younger patients. However, the incidence of cerebrovascular and cardiovascular complications was found to be lower than expected. Patient-graft survival in 110 renal transplants in 106 patients aged 50 years or older were 87% and 76% respectively. These results suggest that cadaveric renal transplantation represents a relatively safe form of therapy also for older patients.

[Initial clinical experiences with allotransplantation of the pancreas]. / Erste klinische Erfahrungen mit der Allotransplantation des Pankreas.

Since 1979 7 pancreas transplantations have been performed in 8 type I diabetics. 5 of these 7 recipients had already been dialysed; 2 were awaiting their first dialysis. Furthermore, diabetes had caused severe retinopathy in 5 patients. The pancreas was transplanted simultaneously with a kidney from the same donor in 5 recipients; in 3 cases the pancreas was grafted 16 to 230 days after successful renal transplantation. 1 pancreas graft was removed immediately after revascularisation because of ischaemic damage. While the pancreatic duct was occluded in the first 4 patients, enteric diversion of the pancreatic juice was applied in the next 3 recipients. The first two patients were treated with conventional immunosuppression, whilst all the others received cyclosporin A and low-dose steroids. Small amounts of insulin had to be given initially for a few days in 2 cases, only. 2 grafts were lost due to surgical complications and 3 for immunological reasons. 1 functioning graft had to be removed because the patient was not willing to continue immunosuppression after irreversible rejection of her renal transplant. There was no perioperative death. 2 pancreatic and 5 renal grafts are functioning well at the present time. Technical aspects and problems in the diagnosis of rejection are discussed.

[Infectious complications in the early phase following kidney transplantation]. / Infektiöse Komplikationen in der Frühphase nach Nierentransplantation.

A retrospective analysis of 533 patients receiving kidney transplantation was performed to study the incidence of infection in the early postoperative period. Mostly localized in the lungs and renal system, bacterial complications arose in 133 patients. As compared with the unproblematic management of the urinary tract infections, 45 pulmonary infections were characterized by difficulties in diagnosis and treatment. Poor graft function was closely related to pulmonary infections: mean creatinine was 2.4 mg% (in patients without pneumonia - 1.5 mg%). Out of 45 patients with pneumonia, the graft failed in 16 patients. 6 patients died as a result of pneumonia. Rapid detection of the pathogenic organism is required, if necessary by invasive diagnosis. The administration of erythromycin before identification of the responsible pathogen may be indicated, in view of the fatal outcome in several patients subsequently diagnosed as having Legionella infection.