How to estimate the size of the donor liver

Of readily available methods to estimate the donor liver size, measurement of the body circumference at the xiphoid level (xiphoid measure) appeared to be the most accurate in the present prospective study of 60 donors and 57 recipients (r = 0.64, P = 0.0001). The estimated liver volume could be calculated using the equation: bloodless liver volume (1) = 1.44 x xiphoid measure (m). The difference between donor and recipient xiphoid measures was significantly higher in slowly recovering patients than in those recovering uneventfully (7 +/- 7 cm vs. - 5 +/- 8 cm, P < 0.001). The bloodless donor liver volume measured by water displacement averaged 1249 +/- 230 ml and had increased by 3 weeks posttransplant by 64 +/- 28% as determined using computed tomography. The volume of the liver graft seemed to adapt to the recipient as it correlated positively with body weight (r = 0.64, P < 0.01) and negatively with the age of the recipient (r = -0.42, P < 0.01). The liver graft volume seemed to increase less markedly in patients with a slow recovery than in those with an uncomplicated recovery (37% +/- 15% vs. 68% +/- 24%, P < 0.001). We conclude that a simple measurement of the body circumference at the xiphoid level can be used to estimate the donor liver volume. A gross mismatch of this parameter between the donor and the recipient seems to increase the risk of graft dysfunction. We also found that the change in the liver graft volume is influenced by the recipient's age and body weight.

Survival modelling in kidney transplantation: hazard rates of graft loss. Transplant Working Group of the Registry Committee of the European Dialysis and Transplantation Association-European Renal Association (EDTA-ERA)

Mathematical modelling of survival data provides long-term projection of graft survival and allows evaluation of the impact of several variables on graft outcome. We analysed 52,315 first cadaveric grafts performed between 1971 and 1985 and reported to the EDTA Registry. We quantified the risk of graft loss using the hazard rates. The hazard function provides the magnitude of the risk of graft loss at a given time post-transplantation. For the 1971 and the 1985 cohorts, the risk of graft loss at 1 month posttransplantation was 143 and 53 per 1000 patient-months, respectively. At 1 year it was 5 and 2.4 per 1,000, respectively. The hazard function thus allowed quantification of the magnitude of the risk of graft loss and its evolution along with time. At 5 years posttransplantation, the risk of graft loss was close to 1 per 1,000, whatever the cohort considered, quantifying the lack of improvement of graft losses in the long term since the early 1970s. It was also possible to evaluate the composition of the risk and to explore the respective influence of graft failure and of patient death.

Doppler ultrasound in the diagnosis of renal transplant artery stenosis--value of resistive index

Doppler ultrasound (DU) with angiographic correlation was performed in 19 hypertensive renal transplant recipients suspected for transplant artery stenosis. DU included calculation of the intrarenal resistive index (RI) and measurement of the maximum systolic velocity in the transplant artery. All 10 cases having a pathologically low RI (< or = 0.6) had a > or = 50% stenosis; specificity and positive predictive values were thus 100%. There were 5 false-negative diagnoses, sensitivity 67%. The measurement of maximum systolic velocity was feasible in only 15 cases (79%). Using a cut-off point of 2 m/s the sensitivity was 91% and there were 4 false-positive cases and one false-negative case. Balloon percutaneous transluminal angioplasty (PTA) was performed in 13 cases, of which 9 were successful. In all successful cases RI was < 0.6 after PTA. We conclude that low RI (< 0.6) is highly suggestive for transplant artery stenosis. RI may serve as an indicator of the hemodynamic success of PTA.

Renal transplantation in children with emphasis on young patients

We report the results of 41 consecutive renal transplantations performed on 39 children (median age 2.7 years). Twenty-six recipients were less than 5 years old. Twenty-one recipients (13 under the age of 5 years) received cadaver (CAD) grafts. All grafts except 2 were from adult donors and were placed extraperitoneally. Patients were on triple immunosuppression (cyclosporine plus azathioprine plus methylprednisolone). Mean follow-up time was 2.3 years. No vascular and only one ureteral complication was seen. Acute tubular necrosis occurred in 3 patients (7.3%). No grafts were lost due to acute rejection. Three-year patient survival and 1-year graft survival were 100%. The overall 3-year actuarial graft survival was 86%. Three-year survival of grafts from living-related donors (LRD) was 92% and that of CAD grafts 75%. In recipients younger than 5 years, 3-year LRD graft survival was '89% and CAD graft survival 73%. No significant differences in graft survival between recipients of different age groups or between LRD and CAD grafts were found. We conclude that results of renal transplantation in children under 5 years of age are comparable to those of older children, even using CAD grafts, when adult donors and triple immunosuppression are used.

Thirty years of renal transplantation in Helsinki

During triple-drug immunosuppression, consisting of azathioprine, steroids, and cyclosporine, the number of acute rejections was low. Close monitoring of the patient and the graft during the early posttransplant weeks with regular cytological and histological analyses was the cornerstone of early diagnosis and a favorable outcome of acute rejection. Genetic homogeneity of our patient population, third-party transfusion program, and use of well HLA-matched kidney grafts may have been additional factors behind the low rate of acute rejection. Acute rejection within the first three postoperative months did not predispose the renal graft to chronic rejection in the long term. The histologically determined allograft damage index was a reliable predictor of future graft survival. Recipients with systemic diseases such as diabetes and amyloidosis, as well as elderly patients, could be transplanted safely with results only slightly inferior to those achieved with primary kidney disease. Results in diabetic recipients have steadily improved, encouraging the continuation of critical evaluation of the patients' pretransplant status and the preference for cadaveric transplants. Renal transplantation in small children yielded superior patient and graft survival rates. We consider the use of living donors justifiable in these cases. The five million population of Finland offers an ideal size for a transplant center. Continuous education of medical personnel and the general public is crucial for the cadaver transplant program.

Reversed diastolic blood flow at duplex Doppler. A sign of poor prognosis in renal transplants

In 25 renal allografts out of 253 with graft dysfunction a reversed diastolic blood flow was observed at duplex ultrasonography during the first post-transplant month. Eleven grafts were lost and 14 survived. The cause of graft loss was arterial thrombosis (n = 1), venous thrombosis or obstruction (n = 4), steroid resistant acute rejection (n = 4) and acute tubular necrosis (ATN) (n = 2). The cause of graft dysfunction in the surviving grafts was ATN (n = 7) and acute allograft rejection (n = 7). Grafts with only peak-like or low velocity continuous diastolic flow reversal had a better prognosis (3 out of 15 were lost) than grafts with any other type of reversed flow pattern (8 out of 10 were lost). This difference was statistically significant (p < 0.01).

Risk factors predicting chronic rejection of renal allografts

Chronic rejection is clinically defined as a gradual but progressive impairment of renal allograft function in the absence of other specific causes. The risk factors predisposing to chronic rejection are incompletely known. In this prospective single-center project, logistic regression analysis was used to study the long-term outcome of 94 consecutive first renal allografts in relation to 10 potential risk factors. Whether serum lipid levels, histopathological changes or the mode of immunosuppressive therapy had a predictive value for chronic rejection was of special interest. The risk factors for renal allograft outcome were determined 2 years after the transplantation, when graft function was still normal, and the results were evaluated 2 years later. Occurrence of acute rejections, cold ischemia time, the high-density lipoprotein cholesterol level, and the high-density lipoprotein and total cholesterol ratio were not significant predictors of graft outcome. In a univariate analysis, triglyceride, total cholesterol, and low-density lipoprotein cholesterol level, and donor age were significantly related to graft outcome. In a logistic regression analysis, triple immunosuppressive therapy was better than any double-drug regimen in preventing the deterioration of renal allografts. Incipient histological changes in graft biopsy, quantitated as the "chronic allograft damage index," was the most important single predictor of chronic rejection. The effect of both the histological changes and low-density lipoprotein cholesterol on adverse graft outcome was level dependent.

Post-transplantation nephrosis in congenital nephrotic syndrome of the Finnish type

Congenital nephrotic syndrome of the Finnish type (CNF) is an autosomal recessively inherited disease manifesting as massive proteinuria, edema and ascites in the neonatal period. The disease is believed to be limited to the kidneys and recurrences after renal transplantation have not been reported. At our center 29 transplantations have been performed on 28 CNF patients. One to 33 months after transplantation, seven grafts (24%) of six patients have developed a steroid-resistant nephrotic syndrome. The clinical data and renal histology of these patients were analyzed in order to elucidate the cause of the proteinuria. At the onset of six of the seven episodes of nephrosis, the patient had evidence of a preceding CMV- or EBV-infection and the remaining patient had sinusitis. Upon light and electron microscopy examination, endothelial swelling of the glomerular capillaries resembling transplant glomerulopathy (TG) was seen, but unlike TG, the glomerular basement membranes were normal. The response of proteinuria to steroid or cyclophosphamide therapy was poor, with total remission in only two patients and partial remission in one patient, all treated with methylprednisolone and cyclophosphamide immediately after the diagnosis. Four grafts have been lost. Our data show that CNF patients have an increased tendency for post-transplantation nephrosis.