The use of single pediatric cadaver kidneys for transplantation.

We have reviewed our experience with 126 single pediatric cadaver kidneys (donor ages 9 months to 16 years) transplanted over a 10-year period. There were 17 donors aged 0-2 years, 55 donors aged 0-6 years, 34 donors aged 7-12 years, and 37 donors aged 13-16 years. One-year patient and graft survival was 88.2%/76.5%, 91%/74%,88.3%/69.1%, and 94.4%/80.6% for the respective groups. One-year patient and graft survival for an adult donor control group was 93%/69%. The percentage of recipients requiring dialysis in the early posttransplant period was 70.6%, 54.5%, 52.9%, 51.4%, and 52.4% for all groups, respectively. The time to reach a nadir creatinine was similar in all groups (24-30 days). While the functional outcome was comparable to cadaver transplantation utilizing adult donor kidneys, a higher incidence of infections and technical complications were encountered in the young-donor-age groups. Overall, there were 12 ureteral complications (8 fistulas, 4 stenoses), 3 bladder fistulas, and 4 renal artery stenoses. The urologic complication rate in kidneys from donors 0-2 years of age was 23.5% (all ureteral fistulas) versus 5% in the kidneys from adult donors. Only one graft was lost due to a technical complication. We conclude that, while cadaver kidneys from donors in the young age groups may be utilized successfully for transplantation, a higher incidence of urologic complications may be associated with their use. Careful harvesting and intraoperative techniques may minimize complications when utilizing kidneys from these donors.

Pretransplant assessment of renal viability by phosphorus-31 magnetic resonance spectroscopy. Clinical experience in 40 recipient patients.

A group of 40 cadaveric kidneys was studied just prior to planned transplantation to further assess the applicability of 31P-MRS in the analysis of clinical renal transplant viability. Renal intracellular high-energy phosphorus metabolites (ATP [or NADP], phosphomonoester [PME] and inorganic phosphate [Pi]) and pH were measured noninvasively with MRS surface coils external to cold storage containers. Pretransplant MRS parameters were correlated with subsequent renal function in recipient patients (measured one week postoperatively by the need of dialysis, drop in serum creatinine, urine output, and 123I or 131I Hippuran assessed renal tubular function). ATP and NADP was detected in eleven kidneys and was significantly (P less than 0.001) associated with the best renal function posttransplantation. These kidneys also had the highest PME/Pi ratios (1.66-0.54), while lower ratios (0.36-0.10) were associated with prolonged acute tubular necrosis. The PME/Pi ratios significantly (P less than 0.0001) correlated with subsequent clinical renal function, whereas cold storage times (37 +/- 10 hr) or intracellular renal pH (6.53-7.91) did not. These preliminary data suggest that MRS is a noninvasive, nondestructive and sterile method for assessing clinical viability during hypothermic storage of human cadaver kidneys and the subsequent recovery of renal function postrenal transplantation.

Immunologic and patient selection strategies for successful utilization of less than 15 kg pediatric donor kidneys--long term experiences with 40 transplants.

Renal transplantation using infant donors is associated with significantly less graft survival (GS) and increased morbidity, especially from very young and small donors. We report our results using specific strategies to determine which age and size donor require en bloc renal transplant reconstruction and associated immunologic protocols for optimization of subsequent GS. Forty cadaveric pediatric en bloc renal transplants were performed. Mean donor age was 23.6+/-18.4 months with subgroups: 2-12 months, n=14; 13-24 months, n=19; and 25-60 months, n=7. Mean donor weight was 14.4+/-4.5 kg. All kidneys were placed in primary, nonsensitized (peak PRA = 7.9+/-5.6%) adult (41.6+/-16 years) recipients. Low weight was preferred (62.4+/-12.8 kg). Mean cold ischemia time was 26.9+/-8.6 hr. Immunosuppression consisted of quadruple immunosuppression (QI) with OKT3 induction. All patients had ureteral stents placed intraoperatively. Mean follow-up was 16.9 months. Actuarial GS at 12, 24, and 33 months were 100% (n=13), 85% (n=20), and 71% (n=7), respectively. Total GS was 35/40=88%. All grafts functioned immediately and there were no technical losses. Biopsy proven rejections occurred in 12 (30%) patients, developing at 16-167 days postoperatively (mean = 50.3 days). Mean serum creatinine at one week and 1, 6, 12, and 18 months were 2.1+/-2.0, 1.5+/-0.8, 1.3+/-0.5, 1.1+/-0.4, and 0.9+/-0.4 mg/dl, respectively. Functional isotopic renography, as well as sonographic monitoring reflected rapid initial and continued growth in these kidneys. Mean BP at 12 and 24 months postoperatively were 145/83+/-18/13 and 122/76+/-20/10 mmHg, respectively, with no significant proteinuria noted. Excellent results with minimal complications utilizing very small and young infant donors can be achieved with QI immunosuppression, and selection of low immune reactive and noncomplicated adult recipients. Additionally, maximal renal dosing by minimizing recipient weight may prevent future hyperfiltration damage.

The risk of transmission of hepatitis B from HBsAg(-), HBcAb(+), HBIgM(-) organ donors.

Liver allografts from HBcAb(+), IgM(-), HBsAg(-) donors can transmit HBV to uninfected recipients. We currently no longer accept these livers for transplantation while continuing to accept the kidneys. The purpose of this study is to determine the risk of donor-transmitted HBV infections from HBcAb(+), HBIgM(-), HBsAg(-) organ donors and determine if the risk of donor-transmitted HBV infections and their severity is dependent on the organ being transplanted. This study consists of a retrospective review of the posttransplant course of recipients of HBcAb(+), HBIgM(-), HBsAg(-) donors accepted at UCSF from 6/85 to 12/93. Transmitted HBV infection was defined as one in which the recipient changed from HBsAg(-) prior to transplantation to HBsAg(+) posttransplant, with no other source. There were 25 of 1190 donors who were HBcAb(+), HBIgM(-), HBsAg(-); 1/42 kidney, 3/6 liver, and 0/7 heart HBsAg(-) transplant recipients of organs from these donors became HBsAg(+) after transplantation. This difference in infection rate (liver vs. kidney and heart) is statistically significant. The clinical course of the liver recipients was also more severe. All of the patients who became infected were HBsAb(-) and HBcAb(-) prior to transplant. We conclude that (1) HBV can be transmitted from HBcAb(+), HBIgM(-), HBsAg(-) organ donors, (2) the rate of transmission is highest and severity of infection is worst in the liver recipients; and (3) we will continue to transplant kidneys from these donors, preferably into immunized recipients.

Preoperative assessment of retroperitoneal pathology by magnetic resonance imaging. Primary leiomyosarcoma of inferior vena cava.

A woman with a retroperitoneal mass was found to have a leiomyosarcoma arising in the wall of the inferior vena cava. The extensive preoperative radiologic findings were compared with those of magnetic resonance imaging. The latter allowed a more precise preoperative diagnosis and determination of tumor origin and extent than any of the other diagnostic techniques.

Localization of abscess in adult polycystic kidney by indium-111 leukocyte scan.

In patients with adult polycystic kidney disease (APKD) infected cysts are difficult to localize with current radiographic techniques, especially those dependent on renal function. Indium-111 leukocyte (In-WBC) imaging is both highly sensitive and effective in detecting and localizing abscesses in patients with renal failure. We report on a patient with APKD and sepsis in whom computed tomography, ultrasound, and physical examination failed to locate the renal abscess, which was found by In-WBC scanning.

Assessment of male infertility: correlation between results of semen analysis and phosphorus-31 magnetic resonance spectroscopy.

To evaluate the usefulness of phosphorus-31 magnetic resonance spectroscopy (31P-MRS) in assessing male infertility, we compared it with conventional semen analysis. Specimens were obtained from otherwise healthy patient groups as follows: group A, 7 fertile control subjects; group B, 12 azoospermic men after vasectomy; and group C, 11 patients presenting for infertility evaluation. Correlations between established semen analysis parameters and the 31P-MRS-derived ratio of glycerylphosphorylcholine to total phosphate (GPC/TP) were investigated. Group A controls had a mean GPC/TC ratio of 0.10 +/- 0.05, which was the same as that of group C. With the exception of significantly lowered motility and normal morphology in group C (p less than 0.001 and 0.05, respectively) semen analysis parameters in these two groups were similar. In contrast, the GPC/TP ratio in group B (0.05 +/- 0.04) was significantly different from the control (p less than 0.05), which appropriately reflected complete vasal occlusion. The results suggest that a significant portion of seminal GPC is derived from epididymal secretion and that 31P-MRS is useful for monitoring the GPC/TP levels when assessing epididymal function and male infertility.

History of the prosthetic treatment of impotence.

Early records of observations of the os penis or baculum in mammals go back to Aristotle. These heritable cartilaginous supports were noted to help the penis during copulation. Prosthetic surgery for treatment of impotence was born from the initial experience with the use of the "artificial os penis" (rib cartilage) in post-traumatic reconstruction in 1936. Slow progress was made with the use of extracavernosal acrylic stents, followed by intracavernosal polypropylene rods, and finally the silicone prosthesis over the next 20 years. The introduction in 1973 of the inert silicone semirigid prosthesis and inflatable prosthesis met with great successes. Most recently (1985), there has been development of self-contained prostheses that are technically more simple to insert. Today, much more is known about specific organic causes of impotence that are amenable to many successful nonprosthetic alternative therapies, adding more stimuli to continued innovations in prosthetic surgery for erectile dysfunction.

Adrenal imaging. Computed tomographic scanning and magnetic resonance imaging.

On the basis of this review and others, adrenal imaging using MRI requires functional biochemical data, such as scintigraphy (NP-59 and MIBG), for cortical adrenal assessment. For medullary hyperfunction such as intra-adrenal pheochromocytomas and neuroblastomas, MRI provides excellent staging and localization. Computed tomography is preferred for biochemically established hyperfunction such as Cushing's and Conn's syndromes.

Complex renal reconstruction.

This article provides a complete review of current renal reconstructive techniques. The techniques described include partial nephrectomy, intrasinusal surgery, anatrophic nephrolithotomy, nonvascular bench procedures with autotransplantation, and allograft partial nephrectomy in renal transplantation. A detailed discussion on renovascular and collecting system anatomy and current indications for these procedures is presented.

Assessment of in situ renal transplant viability by 31P-MRS: experimental study in canines.

In 14 in situ canine renal transplants, intracellular phosphorus metabolites were evaluated by phosphorus-31 magnetic resonance spectroscopy (31P-MRS), performed using surface coils to investigate the usefulness of this technique for assessing renal viability in situ. Group I control kidneys (n = 5) were autografts, as were Group II (n = 5) kidneys: the latter group were subjected to surgically induced vascular ischemia and thrombosis. Group III kidneys (n = 4) were rejecting allografts. Renal flow and function, as measured by 99mTc-DTPA, and findings on histologic examination were correlated with 31P-MRS spectra. Group I kidneys showed excellent viability on both 99mTc-DTPA studies and biopsy evaluation, and their 31P-MRS-derived ratios of phosphomonoesters/inorganic phosphate (PME/Pi) and adenosine triphosphate/Pi (ATP/Pi) were high (1.32 +/- 0.23 and 0.90 +/- 0.36, respectively). In contrast, Group II kidneys demonstrated poor flow and function, histologic evidence of severe ischemia from venous and arterial thrombosis, and significantly (P < 0.005) less viability than controls, as monitored by 31P-MRS PME/Pi (0.58 +/- 0.30) and ATP/Pi (0.20 +/- 0.13) ratios. Group III kidneys also demonstrated poor flow and function with 99mTc-DTPA, and the associated histologically injury was noted to be caused by accelerated rejection and severe vascular damage. PME/Pi (0.24 +/- 0.22) and ATP/Pi (0.10 +/- 0.01) ratios were also significantly (P < 0.005) less than those in controls, reflecting nonviability. The 31P-MRS-derived PME/Pi and ATP/Pi ratios enable a qualitative noninvasive assessment of blood flow-dependent renal viability, but with currently used localization techniques the differentiation between severe ischemia and severe acute rejection was not possible.

A new intracellular flush solution improves renal transplant preservation.

A new renal preservation flush solution (PB-2) has been developed to minimize the ischemic injury processes that occur during hypothermic storage and reperfusion and that can decrease renal viability and survival. Development of the new formulation took into account the intracellular and biological interactions that occur pre- and post-transplantation. PB-2 was compared with the conventional standardized Collins-2 flush solution in the preservation of autografts in dogs and was found to provide significantly improved renal recovery, viability, and survival. Studies to test the new solution in human renal allograft transplant preservation are planned.

[Improved organ survival in transplantation of pediatric kidneys by optimizing donor-recipient size relation]. / Verbesserung des Organüberlebens bei der Transplantation von Kindernieren durch Optimierung des Spender-Empfänger-Grössenverhältnisses.

The risk for renal allograft failure in pediatric renal transplantation (donor age below 3 years) is still high, although it has been reduced by the use of potent immunosuppressive therapies. In this study we report on experience with 80 kidneys of donors below 3 years of age (PD) transplanted at the University of California at San Francisco Hospital in accordance with the policy of minimizing donor-recipient size differences. The graft survival rates were comparable with the results for adult donors, 18-50 years of age (AD, n = 891): at 1 year PD 74.1% vs AD 85.5%, at 2 years PD 70.5% vs AD 80.2%, at 3 years PD 63.5% vs AD 76%; there were no significant differences. The policy of minimizing donor-recipient size differences seems to improve graft survival rates, avoiding the tendency for hyperfiltration phenomena and possibly being responsible for this salutary effect. We conclude that the use of pediatric donor kidneys can yield excellent long-term results independent of primary disease if the donor-recipient size difference is minimized and a potent immunosuppressive regimen is employed.

[Effect of HLA compatibility on the transplanted kidney in relation to recipient age]. / Einfluss der HLA-Verträglichkeit auf die transplantierte Niere in Abhängigkeit vom Empfängeralter.

Donor-recipient histocompatibility, as evaluated by the HLA matching results, plays an important role in the outcome of renal transplants, although much controversy surrounds the benefit of kidney allocation based on HLA typing. In this report HLA matching and survival data on 1,342 transplants performed at the University of California at San Francisco between 1984 and 1992 and treated uniformly by quadruple immunosuppression were analyzed in relation to the recipient's age. With respect to the influence of the increasing number of mismatches from 0 to 6, the analysis revealed decreasing 3-year graft survival rates as follows: 85.4%; 87.3%; 71.3%; 78.2%; 75.8%; 70.9% and 67.5%. Whereas the impact of cold ischemia time and histocompatibility was equally important during the 3-year postoperative period, the essential positive influence of good HLA matching on the long-term graft survival was demonstrated. The children aged between 5 and 18 years were identified as a high-risk group by the analysis, HLA-A incompatibility being attributed to poor graft survival in this age group. With respect to the effect of HLA-A histoincompatibility, the data provide evidence that HLA-A matching results seem to play an important role in graft survival in children, whereas transplants well matched in terms of HLA-B did well in adult recipients. No age difference in the impact of HLA-DR could be detected. In conclusion, HLA matching is still essential. It seems that there are differences in the impact of HLA loci in relation to the recipient's age.