Significance of self-reported sleep quality (SQ) in chronic kidney disease (CKD): the Renal Research Institute (RRI)-CKD study.

BACKGROUND: There has been limited research on sleep quality (SQ) in CKD. METHODS: This prospective cohort study of adults with CKD Stages 3 - 5 at four US centers collected self-reported SQ information from the Kidney Disease Quality of Life (KDQOL) instrument, including an estimated SQ score (0 - 100), and 3 SQ-related questions. "Poor" SQ was defined as SQ score < or = 60. Logistic and multiple linear regression assessed associations between SQ and its potential predictors. Times to death and end stage renal disease (ESRD) were examined using Cox regression. A comparison with SQ in ESRD patients from the Dialysis Outcomes and Practice Patterns Study (DOPPS), was additionally performed. RESULTS: Mean SQ score was 59.4 +/- 23.6 (n = 689), and "poor" SQ was reported by 57%. Mean estimated glomerular filtration rate (eGFR) was 24.9 +/- 10.6 ml/min/1.73 m2. Higher SQ significantly correlated with KDQOL mental and physical component summary scales. Significant predictors of lower SQ score included--younger age, presence of dyspnea, self-reported depression, pain, and itchness. There were no significant pairwise differences in SQ from CKD Stage 3 through ESRD. Self-reported daytime sleepiness was significantly associated with higher risk of mortality prior to ESRD (HR = 1.85, p = 0.02). CONCLUSION: Self-reported "poor" SQ was common in a CKD cohort (Stages 3 - 5) and was not only associated with lower quality of life scores and several modifiable symptoms, but also with higher risk of pre-ESRD mortality. Greater attention to this clinical problem is highly recommended in this high-risk population.

Catheter-related bacteremia in hemodialysis patients: the role of the central venous catheter in prevention and therapy.

Infections are a leading cause of morbidity and mortality in patients with end-stage renal disease. Infections in hemodialysis patients are strongly associated with the use of an indwelling central venous catheter. S. aureus, coagulase-negative staphylococci and Gram-negative rods account for the majority of these infections. The outcome of catheter-related bacteremia depends on appropriate antibiotic therapy and management of the hemodialysis catheter. Most studies note that there is no difference in outcome if the catheter is changed over a guidewire in addition to antibiotic therapy or if the catheter is completely removed and reinserted at a later date. However, bacteremia with certain organisms, particularly S. aureus, is associated with complications. Thus, the data suggests that the catheter needs to be promptly removed in patients developing S. aureus bacteremia.Bacterial biofilm likely has a critical role in the pathogenesis of these infections. Numerous in vitro and in vivo studies have demonstrated both a reduction in infection rate with the use of antibiotic catheter locks as well as a reduction in the production of or eradication of bacterial biofilm. Future studies ought to target, firstly, a reduction in the reliance on central venous catheters; and secondly, the formulation of practical strategies to reduce patient risk for developing catheter-related bacteremia.

Influence of uremia and hemodialysis on the turnover and metabolic effects of glucagon.

To evaluate the mechanism and role of hyperglucagonemia in the carbohydrate intolerance of uremia, 19 patients with chronic renal failure (12 of whom had undergone chronic hemodialysis for at least 11 mo) and 35 healthy control subjects were studied. Plasma glucagon, glucose, and insulin were measured in the basal state, after glucose ingestion (100 g), after intravenous alanine (0.15 g/kg), and during a 3-h continuous infusion of glucagon (3 ng/kg per min) which in normal subjects, raised plasma glucagon levels into the upper physiological range. Basal concentrations of plasma glucagon, the increment in glucagon after infusion of alanine, and post-glucose glucagon levels were three- to fourfold greater in uremic patients than in controls. The plasma glucagon increments after the infusion of exogenous glucagon were also two- to threefold greater in the uremics. The metabolic clearance rate (MCR) of glucagon in uremics was reduced by 58% as compared to controls. In contrast, the basal systemic delivery rate (BSDR) of glucagon in uremics was not significantly different from controls. Comparison of dialyzed and undialyzed uremics showed no differences with respect to plasma concentrations, MCR, or BSDR of glucagon. However, during the infusion of glucagon, the increments in plasma glucose in undialyzed uremics were three- to fourfold greater than in dialyzed uremics or controls. When the glucagon infusion rate was increased in controls to 6 ng/kg per min to produce increments in plasma glucagon comparable to uremics, the glycemic response remained approximately twofold greater in the undialyzed uremics. The plasma glucose response to glucagon in the uremics showed a direct linear correlation with oral glucose tolerance which was also improved with dialysis. The glucagon infusion resulted in 24% reduction in plasma alanine in uremics but had no effect on alanine levels in controls. It is concluded that (a) hyperglucagonemia in uremia is primarily a result of decreased catabolism rather than hypersecretion of this hormone; (b) sensitivity to the hyperglycemic effect of physiological increments in glucagon is increased in undialyzed uremic patients; and (c) dialysis normalizes the glycemic response to glucagon, possibly accounting thereby for improved glucose tolerance despite persistent hyperglucagonemia. These findings thus provide evidence of decreased hormonal catabolism contributing to a hyperglucagonemic state, and of altered tissue sensitivity contributing to the pathophysiological action of this hormone.

Structural requirements for a successful chronic peritoneal dialysis program.

Recently, there has been a decline in chronic peritoneal dialysis (CPD) utilization in several countries. And, in these countries, the percent of patients with end-sage renal disease maintained on CPD is less than nephrologists think is appropriate. The reasons for these problems are uncertain, but it is likely that difficulties with the structural organization of CPD facilities play a contributory role. This paper discusses the structural requirements for a successful CPD program, focusing attention on the following domains: (1) adequate chronic kidney disease education, (2) provision and support of physician training in the principles and practice of CPD, (3) adequate size and organization of CPD centers, (4) development of appropriate support systems within the CPD facility, and (5) development of appropriate continuous quality improvement programs to monitor a variety of domains, including adequacy of dialysis, peritonitis rates, catheter infections and problems, psychosocial status of patients, etc.

Tidal PD: its role in the current practice of peritoneal dialysis.

The role of tidal peritoneal dialysis (TPD) has been the subject of several studies over the past 30 years. The use of the newest generation of cyclers combined with the increasing number of chronic peritoneal dialysis (CPD) patients being maintained on cycler therapy has stimulated a reexamination of the role of TPD in the care of CPD patients. Several studies over the past decade have examined solute clearances with TPD in patients. These studies suggest that TPD does not result in an increase in clearances when compared to conventional intermittent peritoneal dialysis (IPD). TPD is now primarily used for comfort in patients who experience pain at the start of inflow and/or at the end of outflow. In TPD, the presence of at least some fluid in the abdomen during the exchanges generally eliminates these episodes of pain. It has recently been suggested that accurate assessment of drain and fill phases during automated PD may be helpful in redefining a role for TPD in CPD patients. If the 'slow' drainage time can be kept to a minimum, then it is possible that the efficiency of PD could be enhanced. Defining the critical volume and then optimizing the TPD regimen could perhaps increase the clearances noted with TPD.

The spouse's role in home hemodialysis.

The role of the spouse as a factor in the success or failure of home dialysis becomes increasingly important as expectations rise that hemodialysis patients be home-trained. Home hemodialysis offers advantages to the patient but may add stress to the spouse. We present cases illustrating the types of responses spouses have to home hemodialysis. Present conditions are such that the spouse's ability to participate in home hemodialysis may be less affected by aspects of the patient-partner's chronic renal disease than the potential change in the marital relationship that can derive from home hemodialysis. Success in home dialysis is at risk when the spouse is naturally dependent on the patient-partner. These spouses will often require special supportive measures.

Treatment of end-stage renal failure in a defined geographic area.

The treatment of end-stage renal failure was studied in southern Connecticut from 1967 to 1975 by (1) calculating survival rates for center and home dialysis patients and cadaver and living related donor transplant recipients and (2) assessing the quality of life with structured interviews and psychological tests. While the survival rate for our home dialysis and transplant recipients were similar to previously reported data, mortality for our center dialysis patients was slightly higher than previously reported. Quality-of-life testing, disclosed that dialysis patients had a substantial impairment in all parameters. Transplant recipients achieved a better degree of rehabilitation. Physicians and patients should be aware of the problems that they are likely to face; otherwise, expectations and goals may be raised to unreachable and ultimately frustrating levels.

The impact of various cycling regimens on phosphorus removal in chronic peritoneal dialysis patients.

BACKGROUND: The National Kidney Foundation Dialysis Outcome Quality Initiative clinical practice guidelines have suggested that serum phosphate levels be maintained at < or =5.5 mg/dL in patients maintained on dialysis. Over 45% of anuric patients maintained on CAPD have serum phosphate levels >5.5 mg/dL. The present study was designed to address the question whether phosphate removal could be enhanced by increasing the dialysate volume during cycler peritoneal dialysis therapy. METHODS: Medically stable patients maintained on chronic peritoneal dialysis therapy, who were high or high-average transporters and had serum phosphate levels > or =5.5 mg/dL, were invited to participate in the study. The protocol involved measuring phosphate and creatinine clearances at weekly intervals on three different cycler prescriptions consisting of 7 and 12 full cycles or 24 cycles with 50% tidal PD (TPD) over 9 hours. Ten patients agreed to participate. Those patients (n=7) with a BMI > 22 had 2 liter (L) fill volumes and 14 L of total dialysate (7 cycles of 2 L) or 24 L total dialysate (12 cycles of 2 L or 50% TPD with 24 cycles).The patients (n=3) with a BMI < 20 had 1.2 L fill volumes and 8.4 L total dialysate (7 cycles) or 14.4 L total dialysate (12 cycles of 1.2 L or 50% TPD with 24 cycles). RESULTS: The mean age (+/- SD) of the study patients was 50.8 (+/- 9.3) years. There were 6 females, 6 Caucasians and 4 African-Americans. The mean weight of the patients was 71.5 (+/- 24.2) kg and mean height 1.65 (+ 7.6) meters. The mean BMI was 18.3 (+/- 1.27) in the < 20 BMI group and 30.3 (+/- 6.6) in the > 22 BMI group. The mean phosphate clearance (L/night/1.73m 2 ) increased from 3.96 (+/- 1.16) with 7 cycles to 4.71 (+ 1.81) with 12 cycles and 4.51 (+/- 1.61) with 50% TPD. Creatinine clearance (L/night/1.73m 2 ) was 4.74 (+/- 1.74) with 7 cycles, 6.06 (+/- 2.04) with 12 cycles and 5.61 (+/- 2.01) with TPD. CONCLUSION: The present study indicates that there is a significant, 19% (P < 0.005) rise in phosphate clearance by increasing dialysate volume 71% from 7 cycles to 14 cycles compared to a 27% increase in creatinine clearance. With tidal PD, phosphate clearance increased by 12% (p=NS) and creatinine clearance increased 18 % (p, 0.02). This increase in phosphate clearance translates into <50 mg net phosphate removal in 9 hours, assuming a serum phosphate of 6 mg/%. Thus, increasing dialysis cycles and volume results in only a minimal increase in net phosphate removal.

A trial of detecting impending access-graft failure by simplified weekly flow monitoring.

Access graft failure is a major problem in hemodialysis. Monitoring the flow through the access so that impending failure can be detected and prevented seems reasonable, but recent clinical trials have failed to show any benefit of such monitoring. Described here are plans for a clinical trial of a new flow monitoring procedure that measures access flow weekly instead of monthly and, being performed before dialysis, avoids the dialysis-induced changes in graft flow that may have affected earlier trials. The planned trial is to be carried out in two stages, the first to establish the sensitivity and specificity of the new method, and the second (if the results of the first stage warrant it) a controlled trial comparing access-costs and hospitalization days between a monitored group and a matched standard care control group. It is hoped that this trial of the new method will establish it as an effective means of extending access-graft life.

Pharmacokinetics of digoxin and digitoxin in patients undergoing hemodialysis.

The pharmacokinetics of digoxin and digitoxin in patients undergoing long-term hemodialysis were examined to determine which is the preferred cardiac glycoside in this patient population. Absorption curves from 0 to 24 hours after an oral dose of digitoxin were similar in dialyzed patients and in control patients. Serum glycoside concentrations after an oral dose of digoxin were higher in dialyzed patients than in control patients, significantly so from 2 to 24 hours, reflecting the absence of the predominantly renal route of excretion of digoxin. When nine dialyzed patients were placed on a maintenance dose of digoxin, 0.125 mg 5 days a week, serum levels plateaued at 30 days at a mean concentration (plus or minus SE) of 0.84 plus or minus 0.05 ng/ml. Maintenance therapy with 0.1 mg digitoxin 5 days a week resulted in stabilization of serum levels within 30 days at a mean concentration of 19 plus or minus 1 ng/ml. Variability in the serum glycoside concentrations was determined after stabilization of levels during 2 to 19 week follow-up periods with each drug. Variability in serum levels was somewhat increased during maintenance therapy with digitoxin. On the basis of the parmacokinetic data obtained in this study, no clear cut preference for one glycoside over the other could be established.

Revascularization of renal artery stenosis in patients with renal insufficiency.

The incidence and prevalence of end-stage renal disease (ESRD), particularly in the elderly population, have continued to increase in the United States. It is estimated that 10% to 20% of the elderly patients with ESRD have potentially remediable renal vascular disease. The purpose of the present study is to examine the results of renal artery revascularization in 20 patients aged older than 55 years with chronic renal failure (serum creatinine level >2 mg/dL) with proximal renal artery stenosis (RAS) diagnosed by magnetic resonance angiography (MRA) who underwent surgical or percutaneous revascularization. Patients were followed up closely in the postrevascularization period; renal function was monitored and potential complications of the procedure were carefully noted. Four of the 20 patients developed serious complications, including 3 patients with clinically significant atheroembolic disease and 1 patient with renal artery dissection. Seven patients developed greater than 5% eosinophilia. Five of the 20 patients had a deterioration in renal function 3 to 6 months after the procedure, and only 5 patients had a reduction in serum creatinine concentration 3 to 6 months after the procedure. The present study suggests that in elderly patients with chronic renal failure and proximal RAS, revascularization of renal vessels is associated with a high complication rate, and improvement in renal function occurs in only 25% of the patients. Whether revascularization can slow the rate of progression of renal failure remains uncertain and can only be answered by a large prospective trial.

Bilateral renal infarction secondary to paradoxical embolism.

Paradoxical embolism is an uncommon but increasingly reported cause of arterial embolic events. Involvement of the kidney is rarely reported. Autopsy studies suggest, however, that embolic renal infarction is underdiagnosed antemortem. We report a case of bilateral, main renal artery occlusion and acute renal failure secondary to paradoxical embolism. Clinical and laboratory data at presentation were not suggestive of renal infarction. Support for the diagnosis of paradoxical embolism, which most commonly occurs across a patent foramen ovale, was made by contrast echocardiography, which provides a sensitive method for detecting right-to-left intracardiac shunts. The often subtle presentation of renal infarction suggests patients with peripheral or central arterial embolic events should be carefully observed for occult renal involvement. Contrast echocardiography should be performed when renal infarction occurs without a clear embolic source to evaluate for paradoxical embolism.

Differing outcomes of gram-positive and gram-negative peritonitis.

Peritonitis remains the leading cause of patient dropout from continuous peritoneal dialysis (CPD) therapy. Few studies have compared patient morbidity, mortality, and outcome for patients undergoing CPD who develop gram-positive and gram-negative peritonitis. We retrospectively reviewed the charts of patients who developed either gram-positive or gram-negative peritonitis between January 1, 1993, and December 31, 1995. Three hundred seventy-five patients who developed 415 episodes of gram-positive and gram-negative peritonitis were maintained on CPD therapy during this time period. There was no difference in age, race, and sex between patients who developed gram-positive or gram-negative peritonitis. More patients with diabetes developed gram-negative peritonitis than gram-positive peritonitis (53% v 40%, respectively; P < 0.05). Coagulase-negative staphylococcal species accounted for 47% of all gram-positive episodes, whereas Klebsiella organisms, Escherichia coli, and Enterobacter organisms accounted for 63% of all gram-negative episodes. Significantly more patients who developed gram-positive peritonitis continued CPD therapy 2 weeks and 6 months after the onset of peritonitis than patients who developed gram-negative peritonitis (97% v 73%; P < 0.05 at 2 weeks and 81% v 58% at 6 months; P < 0.05, respectively). Nine percent of the patients who developed gram-positive peritonitis died within 6 months after the onset of peritonitis, whereas 21% of the patients who developed gram-negative peritonitis died (P < 0.05). Patients who developed gram-negative peritonitis were significantly more likely to require hospitalization than patients who developed gram-positive peritonitis (74% v 24%; P < 0.001). More patients with gram-negative peritonitis required peritoneal catheter removal than patients with gram-positive peritonitis (18% v 4%; P < 0.001). Thirty-two percent of the patients who developed gram-positive peritonitis re-developed an episode of peritonitis with the same organism compared with only 9% of the patients who developed gram-negative peritonitis. Furthermore, peritonitis recurrence with the same organism within 6 months after the initial episode was noted in 60% of the patients with peritonitis caused by Staphylococcus aureus compared with 24% of patients with peritonitis caused by other gram-positive organisms (P < 0.05). We conclude that the outcomes of gram-positive and gram-negative peritonitis are different. When rates of peritonitis are used to predict outcome, it appears that gram-positive and gram-negative peritonitis rates need to be examined separately.

Patient assessment of quality of care in a chronic peritoneal dialysis facility.

The percentage of patients with end-stage renal disease (ESRD) maintained on chronic peritoneal dialysis (CPD) in the United States remains well less than the percentage in several other countries. Furthermore, there has recently been a decline in the percentage of patients with ESRD in the United States undergoing CPD. The reasons for this decline are uncertain, and investigators have implicated problems with the kinetics of peritoneal dialysis, peritonitis and exit-site infections, and psychosocial stresses imposed by the therapy. Few studies, however, have considered the role of the dialysis facility itself and patient perceptions of the facility as contributing to problems with the long-term acceptance of CPD. This study is designed to examine patients' perceptions of the organization and structure of the peritoneal dialysis facility and their interactions with the facility, focusing attention on areas of patient satisfaction and dissatisfaction with the facility. The study was conducted in a large, freestanding peritoneal dialysis program in an urban area that currently treats 140 patients undergoing CPD. Thirty patients were randomly selected to participate in the present study. A structured interview that included open-ended questions was administered and tape-recorded by a trained interviewer not affiliated with the dialysis unit. Patient responses were then reviewed by two investigators, and a taxonomy of patient satisfaction and dissatisfaction was developed, using a modification of the classification proposed by Concato and Feinstein. Patient responses were then categorized according to the taxonomy. The most frequently cited areas of patient satisfaction included the amount of information and instruction provided by the staff (n = 30), personal atmosphere of the facility (n = 30), efficiency of delivery of the dialysis supplies (n = 23), and availability of the primary nurse (n = 18). The importance of the nurse-patient interaction was emphasized by all 30 patients, whereas the physician-patient interaction was cited by only 14 patients. The most frequently cited area of dissatisfaction noted by all 30 patients concerned the dialysis regimen itself. The present study focuses attention on patient perceptions of their CPD facility, identifying areas of satisfaction and dissatisfaction. The analysis is important not only in providing a framework for CPD facilities with which to review their own interactions with CPD patients, but also for identifying those areas that require attention to maintain the long-term viability of CPD therapy.

Evaluating patients with renal failure for renal artery stenosis with gadolinium-enhanced magnetic resonance angiography.

The incidence and prevalence of end-stage renal disease (ESRD) continues to increase, especially in the elderly population. The role of renovascular disease in contributing to ESRD is still not well defined. The objective of this study was to determine the utility of gadolinium (Gd)-enhanced magnetic resonance angiography (MRA) in evaluating elderly patients with renal insufficiency for renal artery stenosis (RAS). A 7-month prospective study conducted in a tertiary referral center evaluated 40 consecutive patients with progressive renal insufficiency (18 men and 22 women; mean age, 70 +/- 5.6 [standard deviation] years) and high clinical suspicion for renovascular disease with Gd-enhanced MRA. Digital subtraction angiography (DSA) was obtained in only those patients with significant RAS detected by MRA. Twelve patients had significant RAS. Six of these patients had percutaneous transluminal renal angioplasty (PTRA), five patients had renal artery bypass surgery, and one patient had a stent placed after PTRA. Seventy-eight renal arteries were satisfactorily evaluated by MRA. Twenty-two renal arteries were evaluated by both MRA and DSA. Of the 12 significant stenoses detected by the MRA, 11 were confirmed by DSA and 1 was confirmed at the time of surgical revascularization. It is concluded that Gd-enhanced MRA is a useful test for the evaluation of RAS in patients with compromised renal function.

Identification and treatment of depression in a cohort of patients maintained on chronic peritoneal dialysis.

Depression is the most commonly encountered psychological problem in patients with end-stage renal disease (ESRD). Depression has recently been shown to significantly impact on the morbidity and mortality of patients undergoing therapy for ESRD. The present study was designed as a pilot study to evaluate the feasibility of screening a large cohort of patients maintained on chronic peritoneal dialysis (CPD) for depression and then pharmacologically treating those patients assessed to have clinical depression. One hundred thirty-six patients maintained on CPD in our CPD unit were screened for depression using the Beck Depression Inventory (BDI), a self-administered questionnaire. Patients with scores of 11 or greater were referred to a trained psychiatric interviewer for further evaluation to confirm the diagnosis of clinical depression and determine whether the patient was a candidate for antidepressant medication. Sixty-seven patients had BDI scores of 11 or greater, and 60 of these patients were asked to participate in further evaluation and possible therapy. Only 27 patients agreed to further study and were evaluated by a trained psychiatric interviewer for clinical depression. Twenty-three of these patients were assessed to have clinical depression, and 22 patients were eligible for antidepressant medication based on their scores on the Hamilton Depression Scale and psychiatric interview. Eleven patients completed a 12-week course of therapy with antidepressant medication, and their BDI scores decreased from a mean of 17.1 +/- 6.9 (SD) to a mean of 8.6 +/- 3.2. Seven patients were treated with sertraline, 2 patients with bupropion, and 2 patients with nefazodone. It is concluded that (1) depression is commonly present in patients maintained on CPD, (2) the BDI is a useful tool to use to screen for clinical depression, and (3) clinical depression is treatable with medication in this patient population.

Continuous peritoneal dialysis and the extended care facility.

The projected disproportionate increase in the number of elderly patients reaching end-stage renal disease constitutes a dramatic change in dialysis demographics. The nursing home or extended care facility (ECF) will become an increasingly important feature of care for both rehabilitation and long-term patient management. For continuous peritoneal dialysis (CPD), the ECF has been critically evaluated in only a single specialized, university-based, geriatric facility that included trained peritoneal dialysis nurses providing care. We have trained multiple ECF personnel in 10 community-based ECFs to provide all CPD-related therapy for 93 patients between November 1993 and December 1998, for a total of 289.3 patient-months. All ECFs have maintained their CPD program. Outcome measures, including hospitalization, mortality, technique failure, and peritonitis rates, show the success and feasibility of using community-based ECFs for CPD. The use of multiple ECFs for CPD appears to offer distinct advantages over solo structured ECF programs without jeopardizing outcomes. A highly structured CPD education program for ECF personnel by nephrology staff is manageable and appears critical for the success of maintaining CPD in the ECF.

A multicenter study of noncompliance with continuous ambulatory peritoneal dialysis exchanges in US and Canadian patients.

Recent evidence suggested that noncompliance (NC) with continuous ambulatory peritoneal dialysis (CAPD) exchanges may be more common in US than in Canadian dialysis centers. This issue was investigated using a questionnaire-based method in 656 CAPD patients at 14 centers in the United States and Canada. NC was defined as missing more than one exchange per week or more than two exchanges per month. Patients were ensured of the confidentiality of their individual results. Mean patient age was 56 +/- 16 years, 52% were women, and 39% had diabetes. The overall admitted rate of NC was 13%, with a rate of 18% in the United States and 7% in Canada (P < 0.001). NC was more common in younger patients (P < 0.0001), those without diabetes (P < 0.001), and employed patients (P < 0.05). It was also more common in black and Hispanic than in Asian and white patients (P < 0.001). NC was more common in patients prescribed more than four exchanges daily (P < 0.0001) but was not affected by dwell volume. On multiple regression analysis, the independent predictors of NC, in order of importance, were being prescribed more than four exchanges per day, black race, being employed, younger age, and not having diabetes. Being treated in a US unit did not quite achieve significance as a multivariate independent predictor. These findings suggest that NC is not uncommon in CAPD patients and is more frequent in US than in Canadian patients. However, country of residence is less powerful as a predictor of NC than a variety of other demographic and prescription factors.

Leukocyte responses to acute renal transplant rejection.

A retrospective study of the response of the leukocyte count to renal transplant rejection was performed in 159 rejection episodes. Results of the study showed that 1. contrary to what is commonly thought leukocytosis is the least common response to acute rejection and a decrease in leukocyte count is far more common, 2. a sudden decrease in leukocyte count in a previously stable patient can be an early sign of rejection, 3. there is a significantly greater incidence of graft loss in rejection episodes characterized by leukopenia and 4. the risk of infection following rejection is greatest in patients with rejection characterized by leukopenia.

Rejection episodes and patient and graft survival after renal transplantation.

The occurrence of acute rejection episodes following renal transplantation was correlated with one-year patient mortality and graft failure rates in a series of 102 consecutive transplant recipients. Twenty-one patients had two or more rejection episodes in the first two months post transplantation; 17 of these expired or lost their kidney compared to only 5 of 28 patients with no rejection episodes in this time period. Similarly, of the 14 patients who developed a second rejection episode 2--6 months post transplantation, 8 died or lost the graft compared to only 2 of 21 patients who had no rejection episodes in this time period. Thus, the development of a second rejection episode early after transplantation necessitating treatment with high dose prednisone therapy carries an ominous prognosis and suggests that serious consideration must be given to graft removal and subsequent retransplantation.