Is matching for sex and age beneficial to kidney graft survival? Société Française de Transplantation and Association France Transplant

A total of 6889 cadaver kidney grafts carried out in the French transplant network from 1 January 1989 to 31 December 1992 were analyzed using single and multifactorial methods in order to evaluate the impact on graft survival of matching for sex and age between donors and recipients. The mean graft survival rate was 75% at 3 yr with donors between 10 and 50 yr of age compared to 65% for donors under 10 yr of age and 67% at 3 yr for donors over 50 yr of age (p < 0.000001). For child recipients there were no significant differences in graft survival whatever the difference in age with the donor (+/- 10 yr). For young adults (17-49 yr of age) the prognosis at 3 yr was the same (75%) whether the donor was in the same age category or older than the recipient. For older adults (> 50 yr of age) a poorer prognosis was obtained when the donor was 10 yr or more older than the recipient (61% at 1 yr, p = 10(-4)). The grafts performed with male donors had a better prognosis (76% at 3 yr) than those using female donors (71% at 3 yr, p < 0.0002). The poorest results were obtained with female donors when the recipient was male (70% at 3 yr). The results of the multivariate analysis of seven parameters involved in graft survival show that the main parameters significantly controlling graft survival are preimmunization before the graft (p = 10(-6)), HLA-DR incompatibility (p = 0.004), retransplantation (p = 0.008), donor sex (p = 0.003), and matching for age between donor and recipient (p = 0.1). These results suggest that age and sex should be considered as criteria in the choice of donors and recipients in organ allocation.

[Multivisceral Kaposi's disease and encrusted pyelitis in a renal transplantation recipient]

Immunosuppression therapy carries inherent risks involving the occurrence of infections and neoplasms. Whereas therapeutic advancement have reduced its frequency, encrusted pyelitis reappears in kidney-transplanted patients and may lead to detransplantation. It is related to chronic urological infections and not inevitably favored by endoscopic explorations. Kaposi's sarcoma is the third cause of tumor in renal-transplanted patients. It is rarely multivisceral and develops exceptionally in the transplant. We report the case of a 60 year-old woman who developed an encrusted pyelitis and a Kaposi's sarcoma in a kidney which was transplanted 14 months earlier.

Insertion of a double pigtail ureteral stent for the prevention of urological complications in renal transplantation: a prospective randomized study

PURPOSE

Urologists successfully use ureteral stents to protect the ureterovesical anastomosis in nontransplant patients.

MATERIALS AND METHODS

We determined the value of ureteral stents in transplant patients. The frequency of urological complications (leaks, obstructions and urinary tract infections) was compared in a prospective randomized series of 194 kidney transplantations (97 with and 97 without a double pigtail ureteral stent).

RESULTS

In the stent group 1 patient had a urinary leak and 35 had urinary tract infections (including 2 cases of Corynebacterium cystitis). In the no stent group 6 patients had urinary leaks, 4 had obstructions and 32 had urinary tract infections. The 1-year patient and graft survival rates were similar in both groups, and renal function at 1 year was also similar (229 versus 208 mumol./l. creatinine in the stent and no stent groups, respectively). A small number of stent related complications occurred (2 stent breakages and 1 stent migration). No stones formed in any case.

CONCLUSIONS

Ureteral stent insertion significantly decreases the rate of vesicoureteral leakage and obstruction in renal transplantation.

Insertion of a double pigtail ureteral stent for the prevention of urological complications in renal transplantation: a prospective randomized study

PURPOSE

Urologists successfully use ureteral stents to protect the ureterovesical anastomosis in nontransplant patients.

MATERIALS AND METHODS

We determined the value of ureteral stents in transplant patients. The frequency of urological complications (leaks, obstructions and urinary tract infections) was compared in a prospective randomized series of 194 kidney transplantations (97 with and 97 without a double pigtail ureteral stent).

RESULTS

In the stent group 1 patient had a urinary leak and 35 had urinary tract infections (including 2 cases of Corynebacterium cystitis). In the no stent group 6 patients had urinary leaks, 4 had obstructions and 32 had urinary tract infections. The 1-year patient and graft survival rates were similar in both groups, and renal function at 1 year was also similar (229 versus 208 mumol./l. creatinine in the stent and no stent groups, respectively). A small number of stent related complications occurred (2 stent breakages and 1 stent migration). No stones formed in any case.

CONCLUSIONS

Ureteral stent insertion significantly decreases the rate of vesicoureteral leakage and obstruction in renal transplantation.

[Surgical technics of kidney transplantation]

The renal transplantation operative technique obeys simple rules which must allow for surgical revision or a new transplantation. Ideally, the first transplantation is performed in the right iliac fossa, in a low, retroperitoneal position. A side-to-end arterial anastomosis is performed onto the external iliac artery, and an end-to-side venous anastomosis is performed onto the external iliac vein. In the case of a right kidney, the renal vein is elongated by means of a vena cava patch graft and the ureter is reimplanted into the bladder according to Gregoir's technique, intubated by a stent. Second transplantations are performed retroperitoneally in the left iliac fossa, according to the same technique. Third transplantations are performed in the right iliac fossa in a high, retroperitoneal position. The end-to-side arterial anastomosis is performed onto the common iliac artery, the side-to-end venous anastomosis is performed onto the origin of the inferior vena cava and the ureterovesical anastomosis is replaced by an uretero-ureteric anastomosis when the approach to the bladder is difficult. As end-to-side or end-to-end arterial anastomoses give virtually equivalent results, it seems preferable to preserve the blood supply of erectile organs by avoiding anastomosis with the internal iliac artery. Among the various urinary anastomoses, uretero-ureteric anastomosis is associated with more complications than the Leadbetter or Cregoir anastomoses. When a Gregoir anastomosis is performed, a long submucosal track must be performed to reduce the risk of reflux, a factor responsible for subsequent acute pyelonephritis. Insertion of a stent appears to facilitate anastomosis and prevents the risk of fistula. Antibiotic prophylaxis is required while the stent is in place.

[Significance of organ donor characteristics in renal function at 1 month: reflection on the allocation of renal transplant]

In a series of 731 kidneys taken from brain-dead donors for renal transplantation, 652 were grafted, and the renal function at 1 month is known for 490 of them. The results show that some donor-related factors influence the outcome of the transplant. In particular, haemodynamic instability refractory to medical treatment is responsible for a 50 mumol increase of serum creatinine one month after transplantation and the use of UW solution during organ collection is responsible for an improvement of serum creatinine compared to other preservation solutions. Haemodynamic instability is a criterion which must be added to those already demonstrated in donors, such as the cause of death, age and sex. The authors propose that donor-related factors be taken into account in the allocation of organs in the same way as immunological factors which, at the present time, constitute the only criterion for kidney allocation.

[Development of a device allowing for the perfusion and preservation of rat kidneys at -4 degrees C]

OBJECTIVES

In order to prolong the cold ischaemia time and to improve the quality of donor kidneys, we have designed and developed a renal perfusion machine allowing the control of perfusion parameters (temperature, pressure, flow rate, resistance) during the various phases of a kidney perfusion and storage protocol at -4 degrees C.

ANIMALS, MATERIALS AND METHODS

Twenty four rat kidneys were removed and the effects of perfusion and storage at -4 degrees C were studied using a perfusion/storage machine allowing the controlled addition of 2,3 butanediol in University of Wisconsin (UW solution). The kidneys were stored for 96 hours at -4 degrees C and were studied in terms of perfusion parameters (pressure, resistance) and according to their histological appearance.

RESULTS

The machine allows controlled perfusion of a cryoprotective agent and preservation of kidneys at -4 degrees C for 96 hours.

CONCLUSION

In animals, it is possible to store kidneys at a temperature of -4 degrees C for 96 hours by using a vecor solution (UW solution) and a cryoprotective agent (2,3 butanediol). The perfusion and storage of organs under these conditions must be performed by a computer-assisted machine, allowing monitoring and control of the various steps of perfusion/storage.

Stimulation of the medial preoptic area of the hypothalamus in the rat elicits increases in intracavernous pressure

Penile erection can be elicited by various stimuli integrated in the spinal cord and/or higher central nervous structures. The medial preoptic area (MPOA) of the hypothalamus is known to play a key role in the regulation of the male sexual behavior. In anesthetized male rats we performed MPOA stimulation via stereotaxically implanted electrodes or canulae delivering L-glutamate. An erectile response, assessed by an increase of intracavernous pressure (ICP), was recorded during electrical stimulation of the MPOA. Stimulating the posterior region of the MPOA elicited a greater erectile response than stimulation applied to the anterior region. Microinjections of L-glutamate also elicited an ICP increase. Stimulation of MPOA neurons therefore elicits activation of neural pathways controlling penile erection.

[Impact of weight difference between donor and recipient on the function of the transplanted kidney]

OBJECTIVE

The objective of this retrospective study was to determine whether the difference between the donor's weight (wd) and the recipient's dry weight (wr) could influence the function of renal transplants.

METHODS

Between 1987 and 1994, 185 patients with a mean age of 43.3 years +/- 12 were transplanted with a locally harvested cadaver kidney, corresponding to 120 men (42.2 years +/- 1.4) and 65 women (45 years +/- 12.8). The weight variation between donors and recipients (wd - wr) was 0.06 for men and 0.22 for women. The serum creatinine of recipients at 1 year was 147 mumol +/- 41.7. We used analysis of variance for univariate statistical analysis and multiple linear regression for multivariate analysis.

RESULTS

On univariate analysis, the serum creatinine at 1 and 2 years was significantly higher (p < 0.02 and p < 0.035 respectively) when the donor's weight was 10% lower than the recipient's weight. Multivariate analysis, taking into account the donor's age and sex and the recipient's serum creatinine, confirmed the influence of the donor-recipient weight difference on serum creatinine at 2 years (p0.03), but also the role of the donor's age at 1 and 2 years (p < 0.0001 and p < 0.0004, respectively).

CONCLUSION

In our study, the donor-recipient weight difference was a factor influencing the recipient's serum creatinine at 2 years. The donor's age also influences the recipient's serum creatinine, 1 and 2 years after renal transplantation.

Occurrence and treatment of kidney graft lithiasis in a series of 1500 patients

In a series of 1500 patients transplanted between 1976 and 1992, 12 patients presented urinary calculi. The symptoms presented included obstructive anuria in 3 patients and abdominal pain in 1 patient. There were 8 asymptomatic patients. The risk factors were mainly hyperparathyroidism and non-absorbable sutures. The occurrence of renal graft calculi is now ten times less frequent than in the 1980s. In all, 5 of the patients were treated using incisional surgery, 5 with ESWL and 4 using ureteroscopy; a double J stent was inserted for the 3 cases of obstructive anuria. Nine patients are currently calculus-free and 2 have relapsed. One asymptomatic patient was not treated. The renal function of these 12 patient was not modified and no hypertension was noted after treatment. Calculi are generally asymptomatic when they are diagnosed by ultrasonography and in our experience they can be treated using ESWL or by ureteroscopy. In our opinion all patients can be treated successfully but with a high rate of relapse if the causal factors are not treated.

[Double kidney-total pancreas transplantation with bladder reimplantation. 25 cases]

Twenty five double kidney-pancreas transplantations were performed according to the total pancreas transplantation technique with drainage of exocrine secretions into the bladder via a vesicoduodenostomy. 72% of kidney-pancreas grafts were functional at one year and 59% were functional at four years. The authors observed a slightly higher rejection rate (0.56 versus 0.34) and a higher incidence of urinary tract infection (60% versus 35%) following double pancreas and renal transplantation than after isolated renal transplantation. Complications were rare: two venous thromboses and two cases of urethritis requiring of rediversion of the duodenum into the intestine. These good results, comparable to those reported in the international registry, reflect the value of the pancreatic and renal transplantation technique using a total pancreas drained into the bladder. It would probably be preferable to transplant patients earlier, when chronic renal failure secondary to insulin-dependent diabetes induces end-stage renal failure and the need for haemodialysis.

[Experimental approach to reflex erection in rats: modeling and functional neuroanatomy of the involved nerve pathways]

The neurophysiology of erection remains poorly elucidated, particularly at the spinal cord level. We studied variation of intracavernous pressure (ICP) in rats. Tactile stimulation of the prepuce in conscious rats induces the appearance of sequences of reflex erectile responses affecting the corpora cavernosa and/or corpus spongiosum and glans. During this test, implantation of a telemetric pressure transducer allowed us to record ICP increases occurring simultaneously to erectile responses. These increases were characterized by brief suprasystolic peaks preceded by an infrasystolic plateau. Each type of reflex erectile response was accompanied by a characteristic profile of ICP increase. Participation of the corpora cavernosa was demonstrated, particularly during erections of the glans. In anaesthetised rats, electrical stimulation of the dorsal nerve of the penis induces an increase of intracavernous pressure which tends to reach blood pressure values. This erectile response of the corpora cavernosa is abolished by proximal section of the dorsal nerve of the penis, markedly decreased by section of the homolateral pelvic nerve, and abolished after bilateral section of the two pelvic nerves. Striated muscle paralysis does not abolish the erectile response. These data help to define the neurophysiology of the reflex erection. In particular, they provide a clearer explanation of the spinal integration of reflex erection.

[Cadaver donor nephrectomy. Surgical technique in the context of multi-organ donation]

95% of renal transplantations performed in France use cadaver donor kidneys. Two donor nephrectomy techniques are proposed: a beating heart technique and an arrested heart technique. In the very great majority of cases (80%), donor nephrectomy can be performed during multi-organ removal, performed according to bioethical regulations: unrelated, anonymity between donor and recipient, security, traceability and evaluation. The urologist has a role to play at each step of organ donation, in which he is the main protagonist. The first steps are performed in close collaboration with the intensive care unit which established the diagnosis of brain death of the potential donor. The following steps, guided by the French transplant establishment, are the urologist's responsibility: He is responsible for abdominal exploration looking for a tumour or any other abnormality. A strictly aseptic technique is essential to prevent contamination of the organ. He is responsible for removing kidneys in such a way as to ensure the shortest possible warm ischaemia time, the best storage solution, and the best preservation of their anatomical structure. He must be familiar with the outcome of transplants in order to adapt his technique to the results of transplants.

Dramatically different phenotypes in mouse models of human Tay-Sachs and Sandhoff diseases

We have generated mouse models of human Tay-Sachs and Sandhoff diseases by targeted disruption of the Hexa (alpha subunit) or Hexb (beta subunit) genes, respectively, encoding lysosomal beta-hexosaminidase A (structure, alpha) and B (structure, beta beta). Both mutant mice accumulate GM2 ganglioside in brain, much more so in Hexb -/- mice, and the latter also accumulate glycolipid GA2. Hexa -/- mice suffer no obvious behavioral or neurological deficit, while Hexb -/- mice develop a fatal neurodegenerative disease, with spasticity, muscle weakness, rigidity, tremor and ataxia. The Hexb -/- but not the Hexa -/- mice have massive depletion of spinal cord axons as an apparent consequence of neuronal storage of GM2. We propose that Hexa -/- mice escape disease through partial catabolism of accumulated GM2 via GA2 (asialo-GM2) through the combined action of sialidase and beta-hexosaminidase B.

Haematogenous dissemination of prostatic epithelial cells during radical prostatectomy

Radical prostatectomy is one treatment for organ-confined prostatic adenocarcinoma. Dissemination of malignant prostatic cells after radical prostatectomy could be partly due to prostate manipulation during dissection. We confirmed by assay of prostate-specific membrane antigen by reverse-transcription nested PCR that prostate manipulation seeded prostatic epithelial cells in the general circulation in 12 of 14 consecutive patients operated on for organ-confined prostate adenocarcinoma. Our results suggest that surgeons should approach radical prostatectomy with care to avoid seeding from the prostate gland. Antiandrogen therapy might reduce the haematogenous spread of prostatic cells during radical prostatectomy.

Enhanced detection of hematogenous circulating prostatic cells in patients with prostate adenocarcinoma by using nested reverse transcription polymerase chain reaction assay based on prostate-specific membrane antigen

We report the development of a new sensitive nested reverse transcription-polymerase chain reaction (RT-PCR) assay, using primers derived from the prostate-specific membrane antigen (PSM) cDNA sequence, to detect an hematogenous spread of prostate adenocarcinoma cells. In 60 patients with a biopsy-proven prostate cancer, PSM and PSA RT-PCR detected circulating prostate cells in 40 and 20 patients, respectively. In pT4 M+ and pT3 M+ disease patients, nested PSM primers detected cells in 28 of 33 patients (85%), whereas nested PSA primers detected cells in 17 of 33 (51%). In patients with organ-confined cancer spread (pT2a and pT2b patients) before radical prostatectomy, nested PSM RT-PCR detected circulating prostatic epithelial cells in 6 of 17 patients (35%), which suggests that an hematogenous spread of prostate cells may occur early in prostate cancer history. Altogether, these results suggest that the detection of PSM-expressing cells in blood may predict the development of cancer in patients without clinically apparent prostate cancer. Nevertheless, the potential application and the clinical significance of detection of hematogenous prostate cells through the use of nested PSM primers need an extensive longitudinal study.

Enhanced detection of hematogenous circulating prostatic cells in patients with prostate adenocarcinoma by using nested reverse transcription polymerase chain reaction assay based on prostate-specific membrane antigen

We report the development of a new sensitive nested reverse transcription-polymerase chain reaction (RT-PCR) assay, using primers derived from the prostate-specific membrane antigen (PSM) cDNA sequence, to detect an hematogenous spread of prostate adenocarcinoma cells. In 60 patients with a biopsy-proven prostate cancer, PSM and PSA RT-PCR detected circulating prostate cells in 40 and 20 patients, respectively. In pT4 M+ and pT3 M+ disease patients, nested PSM primers detected cells in 28 of 33 patients (85%), whereas nested PSA primers detected cells in 17 of 33 (51%). In patients with organ-confined cancer spread (pT2a and pT2b patients) before radical prostatectomy, nested PSM RT-PCR detected circulating prostatic epithelial cells in 6 of 17 patients (35%), which suggests that an hematogenous spread of prostate cells may occur early in prostate cancer history. Altogether, these results suggest that the detection of PSM-expressing cells in blood may predict the development of cancer in patients without clinically apparent prostate cancer. Nevertheless, the potential application and the clinical significance of detection of hematogenous prostate cells through the use of nested PSM primers need an extensive longitudinal study.

Global energetic failure in brain-dead patients

The objective of this prospective, clinical study of consecutive patients was to test the hypothesis of a global energetic failure in brain-dead patients by analyzing indices of peripheral oxygenation during brain-dead resuscitation. Subjects comprised 24 subjects with brain death criteria from a multidisciplinary intensive care unit. The causes of brain death were multiple: severe traumatic head injury, cerebrovascular event, cerebral anoxia, primary brain tumor, and gunshot wound to the head. Interventions used were radial and pulmonary artery catheterization. Hemodynamic and gasometric parameters and blood lactate levels were measured immediately after the diagnosis of brain death (T0) and 4 hr later (T4), while patients were receiving a therapeutic protocol (fluids, vasopressive drugs) adjusted to reach a mean arterial pressure of 75 mmHg. In 18 of our 24 patients, a blood lactate level > or = 2 mmol/L (mean +/- SD: 4 +/- 2 mmol/L) associated with an increased mean lactate to pyruvate ratio (14.4 +/- 3.2) was observed at T0, while oxygen delivery (DO2) was high (533 +/- 208 ml/min/m2) and mean arterial pressure was 76 +/- 21 mmHg. Patients were subdivided into two groups according to changes in DO2 from T0 to T4: group D comprised 14 patients (10 with hyperlactatemia and 4 with normal lactate) in whom DO2 and oxygen consumption (VO2) simultaneously decreased from T0 to T4 without significant change in lactate level; group I comprised 10 patients (8 with hyperlactatemia and 2 with normal lactate) in whom DO2 and VO2 simultaneously increased, while the blood lactate level decreased significantly from 3.5 +/- 2.5 mmol/L at T0 to 2.1 +/- 1.0 mmol/L at T4 (P < 0.05). Our results indicate that the brain-dead state was frequently associated with a global energetic failure probably due to a cellular oxygen deficit, despite blood pressure within the normal range. This energetic failure, because it is associated with high levels of DO2, could result from a defect in peripheral oxygen extraction. Aggressive therapy, achieved by producing a further increase in DO2, may reduce this global tissue oxygen deficit.