One hundred kidney transplants in the Belfast city hospital

Corticosteroids in Solid Organ Transplantation: Update and Review of the Literature

Corticosteroids have been a constant in immunosuppressive regimens since the beginning of solid organ transplantation. Although the use of corticosteroids allowed the advancement of transplantation in the early years, this came at the price of numerous adverse events for patients. As the survival of transplanted organs has risen over the past several years, increasing attention has been focused on the management of long-term complications. Many of these long-term complications are directly related to the toxicities of immunosuppressive agents. Due to these toxicities, we have seen a resurgence in immunosuppressive protocols that utilize regimens designed to minimize these long-term complications. This has been accomplished by avoiding, reducing or withdrawing one or more medications from the multi-drug regimens. Corticosteroids, with their plethora of side affects, have been of major interest to the transplant community in terms of minimizing side affects by limiting exposure.

The evolution of renal transplantation in clinical practice: for better, for worse?

BACKGROUND

Kidney transplantation is the optimal form of renal replacement therapy for most patients with end-stage renal disease. Attempting to improve graft and recipient survival remains challenging in clinical practice.

AIM

To identify the factors that have significantly changed over the past four decades and assess their impact on renal transplant outcomes.

DESIGN

Retrospective review of all renal transplant procedures in a single UK region.

METHODS

All 1346 renal transplant procedures performed between 1 January 1967 and 31 December 2006 were reviewed. Clinical data, histological reports and outcomes were available from a prospectively recorded database. The study period was divided into four decades to assess the changes in renal transplantation over time.

RESULTS

Significant changes that have occurred include an increase in donor and recipient ages, a greater proportion of recipients with diabetic nephropathy, a longer wait before the first transplant procedure, a fall in the incidence and impact of acute rejection, a smaller proportion of deaths due to cardiovascular disease, (P < 0.001 for all) and a trend to increased deaths from malignancy (P = 0.06) over time. In multivariate analysis, death censored graft survival was significantly influenced by the era of transplantation, donor and recipient ages, living vs. deceased donor status, and histological evidence of acute rejection, chronic allograft nephropathy, or disease recurrence. Significant factors in recipient survival were the era of transplantation, recipient age, a primary renal diagnosis of diabetic nephropathy or unspecified chronic renal failure, and biopsy proven acute rejection.

CONCLUSION

There have been major changes in the clinical practice related to renal transplantation over the past four decades; some have been beneficial and others detrimental to survival. Regular review of outcomes is essential to guide renal services development and maximize graft and recipient survival.

Prevention of transplant rejection: current treatment guidelines and future developments

In the past 2 decades, progressive improvements in the results of organ transplantation as a therapeutic strategy for patients with end-stage organ disease have been achieved due to greater insight into the immunobiology of graft rejection and better measures for surgical and medical management. It is now known that T cells play a central role in the specific immune response of acute allograft rejection. Strategies to prevent T cell activation or effector function are thus all potentially useful for immunosuppression. Standard immunosuppressive therapy in renal transplantation consists of baseline therapy to prevent rejection and short courses of high-dose corticosteroids or monoclonal or polyclonal antibodies as treatment of ongoing rejection episodes. Triple-drug therapy with the combination of cyclosporin, corticosteroids and azathioprine is now the most frequently used immunosuppressive drug regimen in cadaveric kidney recipients. The continuing search for more selective and specific agents has become, in the past decade, one of the priorities for transplant medicine. Some of these compounds are now entering routine clinical practice: among them are tacrolimus (which has a mechanism of action similar to that of cyclosporin), mycophenolate mofetil and mizoribine (which selectively inhibit the enzyme inosine monophosphate dehydrogenase, the rate-limiting enzyme for de novo purine synthesis during cell division), and sirolimus (rapamycin) [which acts on and inhibits kinase homologues required for cell-cycle progression in response to growth factors, like interleukin-2 (IL-2)]. Other new pharmacological strategies and innovative approaches to organ transplantation are also under development. Application of this technology will offer enormous potential not only for the investigation of mechanisms and mediators of graft rejection but also for therapeutic intervention.

Survey of antibiotic prophylaxis in European renal transplantation practice

Death and morbidity resulting from infection in the immunosuppressed patient following renal transplantation has been much reduced as immunosuppressive regimens have become less aggressive. Such complications, however, remain a considerable risk to transplant recipients and the use of prophylactic antibiotics has been advocated. This survey documents current practices and attitudes to the use of antibiotic prophylaxis in renal transplantation centres throughout Europe on the basis of response to a postal questionnaire.

Ten-year results of renal transplantation with azathioprine and prednisolone as only immunosuppression

93 patients received 102 renal transplants between 1968 and 1977. 99 grafts were from cadavers and 3 were from live donors; 93 were first grafts, 7 were second, and 2 were third. At 10 years total actual patient survival was 66.6%. 50 (55.5%) of 90 first cadaver grafts, and 52.2% of all cadaver grafts, survived at 10 years. Cardiovascular disease was the commonest cause of death, being responsible for 18 of 31 deaths (58%).

The therapeutic use of azathioprine in renal transplantation

This review discusses the pharmacokinetics, mechanism of action, clinical use, toxicities, drug interactions, and possible approaches for therapeutic monitoring of azathioprine (AZA). The drug has been used extensively in posttransplant immunosuppressive protocols. Its therapeutic use is hampered by the development of toxicities, however, especially leukopenia, which is a common criterion for dosage adjustment. Azathioprine is rapidly converted in the liver and erythrocytes to 6-mercaptopurine (6MP), which is eventually metabolized to inactive 6-thiouric acid (6TU). The terminal half-lives of AZA and 6MP are 50 and 74 minutes, respectively. While renal dysfunction does not alter the disposition of AZA, hepatic insufficiency attenuates the pharmacologic activity. Immunosuppression depends on the formation of active intracellular thiopurine ribonucleotides, although AZA itself may block antigen recognition. Individualization of AZA regimens by determining tissue concentrations of thioguanine nucleotides, and plasma concentrations of AZA, 6MP, or 6TU may improve the risk:benefit ratio.

Corticosteroid agents in renal disease

Corticosteroid agents have a major role in the treatment of several renal disorders which have an immune basis. They remain the treatment of choice for minimal-change glomerulonephritis, inducing remission in over 90% of patients. The role of corticosteroid therapy in patients with membranous glomerulonephritis remains controversial, although an extensive controlled trial indicated benefit from a two-month course of alternate-day therapy. Intravenously-administered methylprednisolone has been shown to benefit rapidly progressive crescentic glomerulonephritis; the benefit is probably comparable to that which is obtained with immunosuppression and plasma exchange. Corticosteroid therapy has improved dramatically the prognosis of glomerulonephritis that is associated with systemic lupus erythematosus and the various forms of vasculitis (excluding Wegener's granulomatosis), although the concomitant use of immunosuppressive therapy in these disorders reduces the required doses of corticosteroid drugs. For the last 20 years prednisolone and azathioprine have been standard therapy to prevent renal allograft rejection. However, corticosteroid agents are used currently in much lower doses or have been replaced by cyclosporin A.

Towards the Belfast immunosuppressive regimen: a prospective trial of low versus high dose steroids and once versus twice daily immunosuppression

The Transplant Unit in Belfast achieves the highest survival rates in Great Britain for renal transplants. The immunosuppression used comprises azathioprine and very low doses of steroids administered just once a day. The importance of these features has been examined in two clinical trials using (a) high or low dose steroids with azathioprine, (b) low dose steroids with azathioprine given once or twice daily following cadaveric renal transplantation. Low dose steroids were no more effective than were high dose steroids in preventing graft rejection and there was no advantage in administering immunosuppression once daily in the morning as opposed to twice daily in divided doses. None the less, with low doses of steroids the complications of cushingism and obesity were markedly reduced. Neither trial achieved the degree of success in transplant survival that has been usual in Belfast.

Renal transplantation in Uppsala

The history and progress of organ transplantation in Uppsala are reviewed. Renal transplantation was begun in 1969, and the programme now comprises 50 to 60 transplants per year. Since 1976 the operation is performed at the department of urology. Close collaboration has been established with other departments in the hospital, especially with the medical nephrology unit. The indications for active management of uraemic patients have broadened, and maintaining resources on a par with the demands has constantly been a problem. This report concerns immunosuppressive therapy, transplantation results and research connected with the transplantation programme and deals briefly with the prospects for Uppsala as a transplantation centre in the future.

Fine-needle biopsies of renal transplants in clinical rejection monitoring

Fine-needle aspiration biopsy( FNAB) of renal allograft transplants has been used at Uppsala University Hospital for 3 years. Experience from 51 consecutive patients (from 1 1/2 years) with 333 FNAB was reviewed. Representative material was obtained in more than 70% of the biopsies. Eleven rejection episodes in 12 patients were confirmed with this method. One was not recognized. Significant inflammation in the kidney without clinical rejection was found in 22 patients. The possible causes of such inflammation are discussed. Repeatedly recorded inflammation in the kidney with minor or no effect on graft function may sometimes be caused by viral infection. The clinical value of FNAB in various immunosuppressive regimens is discussed.

The effect of the dosage of steroids on the incidence of cytomegalovirus infections in renal transplant recipients

In a retrospective survey of 92 cadaver renal transplant recipients, cytomegalovirus (CMV) infections were detected in 23 of 34 (68 per cent) patients treated with high doses of steroids but in only 27 of 58 (47 per cent) patients given low doses. Pretransplant blood transfusions were associated with both an improvement in one-year allograft survival-rates (P less than 0.05) and an increase in the incidence of CMV infections. When standardised for any transfusion effect, the incidence of CMV infections was significantly higher in those patients given high doses of steroids (P less than 0.05). In the same group of patients, moreover, CMV infections were associated with a statistically significant increase in the renal allograft survival-rate (P = 0.03).

Improved results of cadaver renal transplantation with azathioprine, prednisone and antilymphoblast globulin

From 1980 to 1982, 100 consecutive cadaver renal transplants were performed. All but 2 recipients received preoperative transfusion and all received an initial 2-week course of antilymphoblast globulin. A prospective controlled evaluation of high versus low maintenance prednisone, and antilymphoblast globulin versus intravenous methylprednisolone for first rejection therapy was done. Over-all 1-year graft and patient survivals were 77 and 96 per cent, respectively. Graft survival was equal in the high and low steroid groups. Antilymphoblast globulin was as effective as intravenous methylprednisolone in reversing first rejections. Graft survival was improved with better donor-recipient matched grafts. We conclude that excellent results can be obtained in transfused cadaver renal allograft recipients managed with azathioprine, prednisone and antilymphoblast globulin. The regimen of prophylactic antilymphoblast globulin, low maintenance prednisone and antilymphoblast globulin alone for first rejections is immunologically effective and steroid sparing.

High versus "low" dose corticosteroids in recipients of cadaveric kidneys: prospective controlled trial

Corticosteroids have the major role in the immunosuppressive treatment of patients who have received renal transplants. Despite their extensive use there is still debate about the appropriate dose that will prevent rejection of the renal allograft with the least morbidity. From March 1979 to November 1981 a randomised controlled trial of high (33 patients) v low oral dose (34 patients) of prednisolone along with azathioprine was conducted in recipients of first cadaveric transplants who had received a blood transfusion within six months of transplantation. The main difference in outcome between the two groups was a high incidence of some infections in the high dose group. Patient mortality, graft survival, transplant function, and number of rejection episodes were indistinguishable in the two groups, but rejection episodes tended to occur later in the high dose group. These findings suggest that the use of lower doses of corticosteroids soon after cadaveric renal transplantation does not jeopardise graft survival and results in lower patient morbidity.

Disseminated tuberculosis in a renal transplant recipient

A case of disseminated tuberculosis in a renal transplant recipient is presented. Tuberculosis can occur in the early postoperative period and is potentially curable. It should be vigilantly looked for in every case of post-transplant infection.

Time of day of taking immunosuppressive agents after renal transplantation: a possible influence on graft survival

Large-amplitude circadian rhythms in immune responses and the known variations in the effects of glucocorticoids with the time of day of administration suggest that immunosuppressive regimens may need to take this variable into account. In two similar groups of patients with renal transplants functioning satisfactorily after three months subsequent graft failure developed in 66% of those taking all immunosuppressives in the evening, compared with only 22% of those taking immunosuppressives twice daily (p < 0.05). A survey of other transplant units showed that one unit with outstanding results--graft survival at three years 82%--had a unique policy of morning-only administration of immunosuppressives. Doctors need to consider more carefully the time of drug administration when prescribing, as it may be possible to obtain better results with less toxicity.

Renal transplantation--a tale of two cities

In 1974 three members of the transplant team from the Western Infirmary in Glasgow moved to the new medical school in Leicester. The initial experience with 33 patients transplanted in Glasgow was published in 1972 and this paper compares the results of that series with the first 21 patients grafted in Leicester.

Despite improvements in tissue typing, better quality donor kidneys and fewer complications, there has been a failure to improve on the levels of graft survival. The overall one year graft survival rate in the Glasgow series was 79 per cent compared to 52 per cent in Leicester. In these two series the difference in results appears to be explained by blood transfusion. All the Glasgow patients had been poly-transfused but of the Leicester patients the 10 transfused pre-transplant had a one year graft survival of 90 per cent while in the 11 non-transfused patients the one year graft survival was only 18 per cent.

Urological complications in 119 consecutive renal transplants

One hundred and nine patients undergoing 119 transplants have been followed up from 8 months to 9 years. Urological complications occurred in 16 transplants, an incidence of 13.4%. Ureteroneocystostomy was performed primarily in all cases; in 98 by the conventional Politano-Leadbetter technique with 9 (9.2%) urological complications and in 32 by an extravesical technique with 7 (21.8%) urological complications. One patient died as a result of ureteric obstruction, without operation. In 3 patients with lower ureteric obstruction, transurethral ureteric meatotomy was successful in 2 cases and resulted in no change in renal function in the third. Two patients with urinary fistulae were managed successfully by continuous drainage with indwelling urethral catheters. The remaining 10 patients required 12 open surgical procedures for relief of ureteric obstruction, with improvement in function in 7 patients.