[Post-transplantation lymphoproliferation in patients with intensive immunosuppression]

Organ allograft recipients are at higher risk for malignancies development. This risk is known to be different in different types of tumours. Skin cancers and lymphoproliferative disorders have been described to be ones the most frequent (comprising 15-25% of all malignancies). Here, we present the case of expansive formation localized near the renal allograft in patient, whose native kidneys failed as a consequence of long-term cyclosporine A therapy after orthotopic heart transplantation. The maintenance immunosuppression consisted of combination of cyclosporine A, mycophenolate mofetil and steroids. The expansion offside of transplanted kidney was detected by routine ultrasound examination. After indifferent neurological symptoms, sepsis, and then multiorgan failure occured. Shortly after acute surgery patient died. Autopsy and histopathology showed lymphoproliferative disorder--mo- nomorphic type of posttransplant lymphoproliferative disorder (PTLD). Occurence of PTLD in organ transplantation is discussed.

Intrarenal gene expression of proinflammatory chemokines and cytokines in chronic proteinuric glomerulopathies

Proteinuria has been recently shown to be an independent risk factor for the progression of chronic nephropathies, but the actual mechanisms by which urinary protein load damages renal tissue in humans remain unsolved. Using real-time RT-PCR method we evaluated intrarenal mRNA expression of various cytokines and chemokines in patients with biopsy-proven IgA nephropathy (IgAN, n=11), membranous nephropathy (MN, n=6) and focal and segmental glomerulosclerosis (FSGS, n=6) who exhibited proteinuria over 0.5 g/day. There was a significant positive correlation between the proteinuria extent and the intrarenal RANTES (regulated upon activation normal T cell expressed and secreted) mRNA expression in patients with IgAN, a similar trend was also observed in patients with MN and FSGS. There were no clear relationships between the proteinuria and intrarenal mRNA expression of tumor necrosis factor alpha, transforming growth factor beta1 and monocyte chemoattractant peptide-1. There were no differences in the pattern of cytokine mRNA expression between different glomerulopathies. In conclusion, our results support the hypothesis that lymphocytes, macrophages and their products provoke tissue injury in response to proteinuria independently of the nature of renal diseases in man.

TGF-beta1 expression and chronic allograft nephropathy in protocol kidney graft biopsy

Chronic allograft nephropathy (CAN) represents a frequent and irreversible cause of long-term renal graft loss. TGF-beta1 is a key profibrogenic cytokine associated with CAN pathogenesis. Because of clinical diagnostic inaccuracy, protocol biopsy has been suggested to be a beneficial method for early CAN detection. Protocol core biopsy was carried out in 67 consecutive cyclosporine-based immunosuppression-treated kidney transplant recipients with stable renal function 12 months after renal transplantation. Biopsy specimens were analyzed morphologically according to Banff-97' criteria and immunohistologically for TGF-beta1 staining. The data obtained were correlated with plasma TGF-beta1 levels and clinical data. CAN (grade I-III) was found in 51 patients (76 %). CAN grade I was found to be the most frequent one (44 %). A normal finding within the graft was made in only 12 patients (18 %). Clinically silent acute rejection Banff IA was present in 4 patients (6 %). In 8 patients (12 %) with CAN, borderline changes were present. We found a significant correlation between CAN grade and creatinine clearance, as measured by the Cockroft-Gault formula (p<0.01) as well as body mass index (p<0.01). There was a significant correlation between chronic vasculopathy (Banff cv) and creatinine clearance, and between the degree of TGF-beta1 staining and chronic vasculopathy (p<0.01). There were no relations between morphological findings and TGF-beta1 plasma levels, cyclosporine levels, plasma lipids, HLA-mismatches, panel reactive antibodies (PRA), proteinuria, and the donor's age. In conclusion, CAN is a frequent finding in protocol kidney graft biopsies 12 months after transplantation. TGF-beta1 tissue expression is linked with chronic vasculopathy.

[Ischemia of the large intestine after simultaneous kidney transplantation and aortic replacement with a fresh graft in an abdominal aortic aneurysm]

Fresh arterial grafts obtained during multi-organ excisions widen a spectrum of treatment possibilities for obliterating arterial disorders of low extremities or for the abdominal aortic aneurysm in patients waiting for organ transplantation. Between the year 1998 and the end of the year 2002, our work-team performed parallel reconstructions of the abdominal aorta using fresh grafts and cadaverous kidney transplantations in a group of five patients. The simultaneous surgical treatment of the both disorders during a single hospitalization as well as a considerable decrease of the artificial blood vessel prosthesis infection risk during chronic imunosuppression, represent the biggest advantage of this method. On the other hand, the risk of possible surgical complications is increased in these patients. During the operation and postoperation period, our four patients suffered from no serious complications. In case of one patient, ischemic colitis occurred which required surgical revision and subtotal colectomy. In this article, the authors describe the postoperation course of the patient condition with the above complication, which required a close cooperation of surgeons, anesthesiologists and nephrologists, in full detail.

[Initial experience with protocol biopsies in transplanted kidneys]

BACKGROUND

The aim of protocol biopsy after renal transplantation was to assess the prevalence of chronic allograft nephropathy (CTN) and to correlate the degree of CTN with clinical and laboratory data.

METHODS AND RESULTS

In 105 patients with a stabilized graft function, a protocol biopsy was carried out at 1 year after transplantation. CAN was found in 75% of patients, and in 6% an acute subclinical rejection was revealed. Statistically significant correlation was confirmed between CAN and recipient's age, development of acute rejection in the first year posttransplant, serum creatinine, clearance of creatinine, and proteinuria. There was no significant difference in CAN degree distribution between patients treated with cyclosporine-A or with tacrolimus. Twelve months after the biopsy, there was no significant change in kidney graft function. In patients treated with tacrolimus, cholesterol and triglycerides levels were significantly lower than in cyclosporine treated patients Over the next year, these values significantly decreased in both subgroups.

CONCLUSIONS

The CAN was found in the majority of protocol biopsies at 1 year after kidney transplantation; subclinical acute rejection was revealed rarely.

[An unusual manifestation of tuberculosis in a female patient after kidney transplantation. Case report]

Organ transplant recipients are at the increased risk of infection complications. Herein, we present a case of unusual localisation of tuberculosis in renal allograft recipient treated by combination of cyclosporine A, mycophenolate mofetil and steroids. After the non specific prodromes, surgery due to ileus discovered ileocaecal tumour. Microscopically tuberculosis inflammatory process with ulcerations of the intestinal mucosa and classification of the lymphatic nodes, instead of the expected lymphoma was proved to be present. We are discussing the incidence of tuberculosis in relation to immunosuppressive therapy as well as possible pathways of tuberculosis transmission.

Urinary tract infection in patients with urological complications after renal transplantation with respect to long-term function and allograft survival

Urological complications after renal transplantation (urinary fistula, urinary tract dilatation) are frequently associated with urinary tract infections (UTI). We tried to analyse whether urinary tract infection was one of the factors which participated in the lower allograft survival rates and reduced allograft function in urologically complicated (UC) patients. We observed 77 patients after renal transplantation (Tx) of whom 42 had urinary fistula, 32 had urinary tract dilatation a 3 had both complications (I/1992-XII/1996). 100 patients without urological complications represented a control group (N). Obtained data was statistically evaluated using t-test, chi 2-test, correlation analysis. Graft and patient survival rates were assessed using the Kaplan-Meier method. We have found that UC patients after Tx had a worse renal function compared with patients not suffering from this complication. Using Kaplan-Meier methods we have found that graft survival rate in patients with UC is significantly lower than that in the control group (5-year graft survival 0.6 vs 0.82, p < 0.01). On the other hand there were no differences in the 5-year patients survival rate between the followed groups of patients (0.74 vs 0.83). There was no significant correlation between predicted creatinine clearance and followed indicators of UTI--total time of positive urine bacterial cultivation, number of infectious periods and total time of antibiotic therapy. There were no significant differences in graft survival during 5 years between patients with UTI and without UTI. Our results suggest that patients with UC are at increased risk of urinary tract infection. Our findings are in keeping with the assumption that UTI in patients with UC do not significantly participate in the decreased level of graft function and the shorter graft survival rates.

TGF-beta I gene polymorphism in heart transplant recipients--effect on renal function

Renal dysfunction is a severe late complication of heart transplantation (HTx). Transforming growth factor beta I (TGF beta I) is a potent multifunctional cytokine with profibrogeneic effect. TGF beta I gene polymorphism correlates with cytokine production. In the present study, we looked for a predictor of renal insufficiency after HTx. In 175 HTx pts and 268 controls, polymorphism in the signal peptide of the TGF beta gene, substitution of leucine-proline at codon 10 and arginine-proline at codon 25, was evaluated by PCR. Renal function was followed after HTx and was compared with the TGF beta I genotypes. There were no differences in the frequencies of alleles and genotypes of TGF beta I gene in the healthy population and HTx recipients; TGF beta I genotype distribution in recipients with ischemic heart disease and dilated cardiomyopathy was almost identical. Renal function was decreasing in most HTx recipients with time. Progression of renal insufficiency (RI) was worse in patients with Leu at codon 10 (LeuLeu vs. LeuPro p < 0.01, LeuLeu vs. ProPro; p < 0.01). RI progression was also more pronounced in individuals homozygous at codon 25 (ArgArg vs. ArgPro; p < 0.01). In individuals heterozygous at codon 10 (LeuPro), the genotype at codon 25 determined the progression of RI (LeuPro/ArgArg vs. LeuPro/ArgPro; p < 0.05). In our study, we have demonstrated the prognostic significance of TGF beta I gene polymorphism for renal insufficiency in heart transplant recipients.

Characterization of patient antibodies after kidney transplantation

OBJECTIVE

The aim of this study was to characterize patient antibodies before and after cadaver and/or living-donor kidney transplantation and to correlate these data with the clinical course after transplantation.

METHODS

Sera from 69 cadaver, 9 living-related and 2 patients waiting for living-donor kidney transplantation were analyzed by the complement dependent cytotoxicity (CDC) test, flow cytometry (FCXM) and ELISA.

RESULTS

FCXM revealed that 15.0% of patients before transplantation and 16.7% after transplantation had antibodies to donor cells. 10.3% patients were positive before and after transplantation (+/+), while 6.8% developed antibodies early after transplantation (-/+). Analysis of the specificity of those antibodies by ELISA showed that it was directed to: 1) mismatched donor HLA antigens 2) antigens belonging to the same cross-reacting group (CREG) as the mismatched donor antigens 3) HLA antigens not expressed by donor cells or, probably, to non-HLA antigens.

CONCLUSION

Anti-HLA antibodies were detected in patients before and after transplantation and in most cases their anti-HLA specificity could be determined. Fast and precise characterization of antibodies in patients before and after transplantation can be performed by both sensitive methods--FCXM and ELISA--which may help predict the onset of immunological complications and, consequently, improve the prognosis after organ transplantation.

MRP 8/14 and procalcitonin serum levels in organ transplantations

OBJECTIVES

MRP8/14 is a heterodimer of two myeloid calcium-binding proteins associated with different types of acute inflammatory processes. We studied MRP8/14 together with procalcitonin (PCT) serum levels in order to diagnose infectious complications or the rejection process affecting kidney or heart allograft.

METHODS

A total of 419 serum samples was evaluated. MRP8/14 levels were measured by ELISA (BMA Biomed), PCT by a sensitive immunoluminiscent assay ILMA (Brahms Diagn.)

RESULTS

Both parameters showed very low basal levels in healthy subjects (range 303-1,660 ng/ml of MRP8/14; less than 0.08 ng/ml of PCT). A rapid increase in serum levels occurred in response to bacterial infections (MRP8/14 up to 6,230 ng/ml; PCT up to 297 ng/ml). Serum PCT concentration remained low in the presence of kidney allograft rejection, where MRP8/14 levels were increased. An uncomplicated outcome of kidney or heart transplantation did not change basal serum MRP8/14 and PCT levels.

CONCLUSIONS

We conclude that 1) both MRP8/14 and PCT are very sensitive markers of complications in organ transplant recipients (normal values in uncomplicated outcome) 2) combination of both parameters is useful to discriminate between rejection (increased MRP8/14 with normal PCT) and systemic bacterial infection (both parameters increased).

[The urinary tract in graft recipients and urologic complications after kidney transplantation]

BACKGROUND

Urological complications after renal transplantation condition reduce graft survival and function. It may be assumed that an important part, in addition to technical factors during removal and implantation of the organ may be played also by factors of the recipient. The authors investigated whether in the development of some urological complications (urinary fistulae and urinary tract dilatation) also pathological changes of the urinary tract of the recipient, kidney diseases leading to renal failure or the development of urinary flow rate during the first days after transplantation of the kidney participate.

METHODS AND RESULTS

The authors investigated 77 patients after renal transplantation where during the period from Jan. 1992 till Dec. 1996 a urinary fistula developed (42 cases), dilatation of the urinary tract (32) or both complications (3). The control group was formed by 100 patients without urological complications who did not differ as to demographic data, basic immunosuppressive treatment and who had transplantations during the same period and by the same surgical techniques. The assembled data were evaluated statistically, the two groups being compared by means of t-test, chi 2 test and the non-parametric Mann-Whitney test resp. The authors investigated factors which might participate in the quality of the recipient urinary tract, in particular the recipient's age. In the group of urologically complicated cases there were significantly (p < 0.05) more patients above 55 years. There were also more males (67.5% vs. 32.5%, p < 0.05). In further factors such as the ratio of BMI ratio or the underlying kidney disease leading to renal failure and the presence of diabetes mellitus the authors did not record significant differences. The residual urinary flow rate, duration of dialysis treatment before transplantation and the number of transplantations did not differ significantly. The authors tried to evaluate the possible influence of urinary flow rate on the development of urological complications after transplantation of the kidney.

CONCLUSIONS

The assembled findings support the idea that the development of a urinary fistula or dilatation of the urinary tract were not significantly influenced by changes in the urinary tract of the recipient conditioned by the period of the reduced function, as may be assumed on the basis of the time of dialysis treatment. The development of the investigated urological complications was not significantly influenced by the presence of underlying kidney diseases nor by increased urinary flow rate during the first days after transplantation. The authors did not confirm the risk of re-transplantation. An significant effect on the development of urological complications could be exerted by male sex and age above 55 years.

Renal transplantation combined with aortofemoral bypass using a fresh arterial allograft

Aortoiliac atherosclerosis is frequently encountered in renal failure patients waiting for renal transplantation. Staged or simultaneous surgical repair of aortoiliac lesions with renal transplantation is possible at reasonable risk. Arterial reconstruction is most commonly performed using an artificial prosthesis. Another option is the use of a fresh or preserved arterial allograft. In our institute, about 180 cadaveric transplantations are performed each year. Over the past 2 years, three patients with chronic renal failure and obliterative disease of the abdominal aorta and iliac arteries underwent aortofemoral bypass using a fresh arterial allograft combined with kidney transplantation from the same donor. The procedures as well as the postoperative course were uneventful. There was an immediate development of function of the renal transplant. Combined arterial reconstruction and transplantation, managing both conditions at a time, is convenient for the patient mainly because it means undergoing only one general anesthesia during one hospitalization. Moreover, the risk of infection of the vascular prosthesis is somewhat reduced. Disadvantages are that the availability of the arterial allograft is dependent on a suitable donor and the limited body of experience with the behavior of the arterial allograft in patients with chronic immunosuppression.

LF 08-0299 in the prophylaxis and treatment of chronic rejection in a rat aortic allograft model

Chronic rejection is the major cause of late kidney allograft failure. We evaluated the efficacy of LF 08-299 (LF), an analogue of 15-deoxyspergualin, in a rat aortic allograft model of chronic rejection. BN aortic allografts were transplanted to Lew recipients. LF was administered at a dose of 6 mg/kg and 2.5 mg/kg on days 0-20 and 6 mg/kg on days 60-90. CyA was used at a dose of 5 mg/kg on days 0-20. Untreated isografts and allografts were used as controls. Histological changes and immunohistochemistry were monitored sequentially at 8, 12, 16 and 20 weeks. There were no differences in intimal proliferation between LF-treated allografts and untreated or CyA-treated controls. Only a tendency in adventitial infiltration reduction was seen in LF-treated animals. We found a significantly less pronounced reduction in media diameter in LF-treated animals. We concluded that LF 08-0299 is only able to reverse reduction in media thickness in aortic allografts, but not intimal proliferation in this model of chronic rejection.

ACE gene polymorphism and long-term renal graft function

OBJECTIVES

The long-term outcome of transplanted kidneys has not changed substantially and only a minority of grafts survives more than 15 yr. The aim of this study was to determine the influence of ACE gene polymorphism on long-term outcome after renal transplantation.

DESIGN AND METHODS

Using PCR, we evaluated ACE I/D gene polymorphism in a group of patients with long-term graft function (LTF) over 15 yr and compared it with control groups of transplant recipients and population sample.

RESULTS

The distribution of genotypes in the LTF group differed from transplant controls (p < 0.05). Moreover, DD homozygotes in the LTF group had better creatinine clearance (DD: 1.1 +/- 0.3, ID: 0.96 +/- 0.3, II: 0.76 +/- 0.3 mL/s; p < 0.05). There were no differences in genotype distribution between transplant and population samples.

CONCLUSIONS

Results of our study have demonstrated a possible connection between the DD variant of ACE I/D gene polymorphism and excellent long-term graft function.

Ultrastructure of rat aortic grafts

This study compares the ultrastructure of three syngeneic and three allogeneic grafts of rat abdominal aorta (Lewis to Lewis and BN to Lewis, respectively); the tissue was sampled three months after transplantation (TPL). The endothelial plate was preserved and mononuclear cell adherence was absent. In syngeneic grafts the intima and media remained close to normal with well-preserved smooth muscle cells (SMC). The thickened allograft neointima consisted of elongated spindle cells and rich intercellular matrix. The cells were typical SMC without apparent signs of dystrophy or degeneration. On the other hand, most SMC of the media showed complete disruption and disorganization of membrane and organelles suggestive of accomplished necrosis. However, the framework of elastic lamellae was preserved, without apparent ruptures or lytic changes. Intraintimal migration of medial SMC was not recorded while some cytoplasmic strips were seen to extend across the outer elastic lamella (possible rudimentary outgrowth of SMC?). Lymphocytes and histiomonocytic cells (macrophages) were found in the adventitia but not in the destroyed media. Thus electron microscopy elucidated the histological picture of "anuclear allograft media" and confirmed the predominance of SMC in the thickened neointima. However, signs of the mediointimal SMC invasion were not apparent three months post TPL.

[Chronic renal allograft rejection. Part 2. Therapeutic possibilities]

Chronic rejection represents an important cause of renal allograft loss in the long term follow up. New insights into etiopathogenesis of the chronic rejection offer possibilities for experimental therapy. Novel immunosuppressants, such as mycophenolic acid, tacrolimus or rapamycin as well as lipid lowering drugs, angiotensin-converting enzyme inhibitors or AT-1 receptor blockers, may reduce of effects the risk factors on the progression of chronic rejection. In the future, gene therapy may offer additional possibilities to prevent chronic rejection. This review deals with possibilities of prevention of the chronic renal allograft rejection based on experimental evidences and current therapeutic concepts and puts these options into a rational perspective.

Withdrawal of steroids from triple-drug therapy in kidney transplant patients

BACKGROUND

In renal transplant patients with stable graft function, triple-drug immunosuppression may not be necessary, while withdrawal of steroids may eliminate side effects. The primary aim of this study was to assess the risk of rejection after steroid withdrawal.

METHODS

A total of 88 patients with stable graft function and serum creatinine <160 micromol/l, treated with cyclosporin A, azathioprine and prednisone were randomized into group A (n=46) with a gradual prednisone reduction to zero in the course of 6 months, and group B (n=42) on triple-drug therapy without change. At the time of randomization, fine-needle aspiration biopsy (FNAB) was carried out in all of the patients. After stopping steroids, the patients were followed up for a period of 12 months.

RESULTS

Four patients failed to complete steroid withdrawal, three due to rejection, and one due to leukopenia. The proportion of rejection in three patients in group A (6.6%) was not significantly different from rejection in two patients in group B (4.8%). The mean value of serum creatinine was not significantly different in both groups in the course of follow-up. A finding of some degree of immunological activity in FNAB was made in four patients in each group, but none of these patients developed rejection. Compared with group B, significant decreases in serum cholesterol and blood leukocytes were observed in group A. Prednisone withdrawal did not have any influence on hypertension and serum triglycerides.

CONCLUSIONS

Gradual withdrawal of steroids is not associated with a higher risk for rejection and has a beneficial effect on serum total cholesterol levels. FNAB was not a useful tool for predicting rejection.

[Withdrawal of prednisone from a triple combination of immunosuppressive agents after kidney transplantation]

BACKGROUND

Triple-drug immunosuppression may not be necessary in a majority of stabilized patients over 1 year after kidney transplantation. In contrary steroid withdrawal may be beneficial for the patient by elimination of side-effects. The primary aim of this study was assessment of the risk of rejection after the prednisone withdrawal.

METHODS AND RESULTS

88 patients 1 year after the first renal transplantation with stable graft function and serum creatinine < 160 mumol/l treated with cyclosporine-A, azathioprine and prednisone were randomized into group A (n = 46) with a prednisone withdrawal and group B (n = 42) on triple-drug therapy without change. At the time of randomization, fine-needle biopsy was carried out in all of the patients. In group A, the dose of prednisone was gradually reduced to zero in the course of six months and the patients were followed up for the next 12 months. In the group B, patients on triple-drug therapy were followed for the corresponding period of time. 3 patients (6.6%) in group A, and 2 (4.8%) in group B experienced rejection (NS). Mean values of serum creatinine were in the course of follow-up in both groups without any statistical difference. Suspect immunological activity or proved immunological activity in aspiration biopsy was present in 4 patients in each group, but one of them rejected the graft. In comparison with group B, a significant decrease of cholesterol and leukocytes was observed in group A. Prednisone withdrawal had no influence on hypertension and triglyceride.

CONCLUSIONS

Gradual withdrawal of steroids is not associated with higher risks of rejection and has a beneficial effect on cholesterol levels. Aspiration biopsy was of no use for the prediction of rejection.

Morphology and immunohistochemistry of rat aortic grafts

Allotransplantation (TPL) of the abdominal aortic segments of BN donors was performed in 32 Lewis recipients with or without cyclosporin A (CyA) immunosuppression, and the vascular changes were compared to those of 10 syngeneic grafts (Lewis-->Lewis) and to the autologous rat aortae. The vessels were examined 2, 3, 4 and 5 months post TPL by light microscopy, the thickness of intima and media was measured morphometrically and the cell infiltration of adventitia and intima was assessed semiquantitatively. Thirty-six aortae were examined by three-step enzyme immunohistochemistry (proof of selected differentiation, proliferation, cytoskeletal and connective tissue matrix antigens). The adventitia displayed an intense focal and scattered mononuclear cell infiltration; it was more discrete and focal in the intima. This cellularity persisted in the allografts but disappeared from the intima and was reduced in the adventitia of the isografts after four and five months. Disseminated ED1+ activated macrophages were the most prominent population of infiltrates whereas modest numbers of adventitial ED2+ tissue macrophages remained constant throughout the intervals examined. CD4+ cells (focal and scattered) outnumbered (roughly twice) the scattered CD8+ lymphocytes; both these types were rare in the intima. Leukocyte invasion of the media was lacking (except for scarce isolated CD8+ cells in some allografts). In syngeneic grafts the smooth muscle cells (SMC) of media remained intact and the intimal thickening was slight to absent (about 5 microns) four and five months post TPL. On the other hand, the allograft media underwent severe destructive changes (karyolysis, depletion of alpha-SMC actin, focal calcification and general thinning without rupture or aneurysm). The prominent allograft intimal thickening (70-80 microns) was due to the proliferation of longitudinally oriented myointimal cells (alpha-SMC actin, FD2, PCNA and Ki67+) and an increase in matrix substance (strong metachromasia and positivity of chondroitin-sulfate proteoglycan). The deposition of lipids remained discrete, without atheromatous plaques and mural thrombosis. All changes were comparable in CyA-treated and untreated animals. Thus the main lesions of the allografts were (i) persistent mononuclear infiltration chiefly in adventitia, (ii) destruction of medial SMC, and (iii) intimal thickening by proliferation of myointimal cells. At the postTPL intervals examined the proliferation and intimal migration of medial SMC were not apparent and a morphological correlate of significant anti-medial-SMC cytotoxic attack was lacking.

Serum procalcitonin concentrations in transplant patients with acute rejection and bacterial infections

Procalcitonin (PCT) represents a new marker of systemic inflammatory reactions of the body to infections. PCT is selectively induced by severe bacterial infections leading to sepsis or multiorgan dysfunction syndrome. The aim of our study was to test PCT as a postoperative infection marker in heart and kidney transplant patients compared with healthy subjects and patients with localized lung-inflammatory processes without a manifest systemic response. PCT concentrations were measured by an immunoluminometric assay (ILMA) in a total of 419 serum samples. Normal serum levels were in the range of 0.08-0.6 ng/ml. Operative trauma associated with heart (not kidney) transplantation induced a transient increase in PCT levels to 7-10 ng/ml with a decline to normal levels within 2-3 days in most patients. Severe bacterial infections dramatically augmented serum PCT concentrations reaching values of 46-297 ng/ml in the most critical periods. Good response to antibiotic therapy was associated with a decline in serum PCT concentrations. Acute rejection or cytomegalovirus infections did not significantly increase the serum PCT levels. Localized pulmonary infections showed either no, or only a limited increase, in the serum PCT levels (max. 7 ng/ml). We conclude from our data that PCT can be used as a sensitive marker to differentiate systemic bacterial infections from other complications in organ transplantation.

[A negative interference effect of pathologic levels of bilirubin on the determination of serum creatinine]

BACKGROUND

Negative interference of bilirubin with assessment of creatinine concentration is generally known from the biochemical aspect. The objective of the presented work was to find the bilirubin level and creatinine concentration where this phenomenon has actually a clinical impact.

METHODS AND RESULTS

In 200 samples selected at random the bilirubin and creatinine levels were examined by the classical Jaffé method and a method where the effect of bilirubin is suppressed. After dividing the group into 8 sub-groups by bilirubin and creatinine concentrations it was revealed that the interference plays a statistically significant role (p < 0.01) already at total bilirubin concentrations above 70 mumol.l-1. In abnormal creatinine levels the interference is manifested only at bilirubin concentrations above 150 mumol.l-1 (p < 0.001). The degree of interference in the whole group is directly proportional to the bilirubin level (r = 0.5497, p < 0.001).

CONCLUSIONS

At bilirubin levels above 70 to 150 mumol.l-1 its interference with assessment of the creatinine concentration can be so significant that it must be taken into account when evaluating the patient's renal function.

[Pregnancy after kidney transplantation]

In the period 1966-1997 renal allografting was performed in 1746 recipients, 244 of whom were women in fertile age. In 32 of them 45 pregnancies were registered. 29 of them (64%) resulted in abortion, which was spontaneous in 4 and medically advised in 25. There were 16 labours, 4 of them free of any complications; of the latter, hypertension was the most frequent one (8). Of the former, 13 were solved by caesarean section and 3 were vaginal deliveries. Of 15 live babies 7 were immature (one died 1.5 year later of renal failure due to microcystic kidneys). No unfavourable effect of pregnancy on prognosis and on long-term graft function was found.

[Conversion from Consupren sol. to Consupren S capsules in kidney transplant patients]

In a group of patients after transplantation of the kidney with stabilized graft function treated by Consupren sol. combined with prednisone and azathioprin in 20 patients (group A) Consupren sol. was replaced by Consupren S capsules, in 17 patients (group B) Consupren sol. therapy proceeded without any change. To maintain the cyclosporin blood concentration within the therapeutic range it was necessary after the change of drug form in group A to adjust the dosage of the drug in 12 patients of group A while in group B only in one patient (p<0.01). The mean doses and levels of Cy-A however did not change significantly during the three-month investigation period in the two groups and and the bioequivalence of the two preparations was evident. Conversion from Consupren sol. to Consupren S capsules is not associated with the risk of rejection or undesirable effects. It can be implemented at a ratio of 1:1 or 1: the closest dose divisible by 25 (the smallest capsules are 25 mg) and after conversion a check-up or possible modification of the dose is necessary.

Flow cytometry cross-match before kidney transplantation in relation to early postransplant rejection

The aim of this study was to compare flow cytometry cross match (FCXM) results in patients before first kidney transplantation with the incidence of rejection episodes and kidney graft survival after transplantation. Sera of 51 patients obtained immediately before transplantation were tested on spleen cells of respective kidney donors. We found no correlation between a positive FCXM result before transplantation and the occurrence of immunological complications after transplantation.

[Repeat kidney transplantation]

BACKGROUND

The objective of the study was an analysis of results of repeated kidney transplantations (Tx2, Tx3) implemented during the first 29 years of activities of the Transplantation Centre of the Institute of the Clinical and Experimental Medicine in subjects with a different maintenance immunosuppression.

METHODS AND RESULTS

The retrospective study pertains to 134 Tx2 and 17 Tx3 in 134 non-diabetic subjects: 43 of them had during Tx1 and Tx2 (1966-1981 and 1966-1985 resp.) immunosuppression on the basis of azathioprin (Aza, sub-group AA), 42 during Tx1 (1972-85), Aza, while during Tx2 (1984-85) immunosuppression on the basis of cyclosporin (CyA, subgroup AC) and 49 both during Tx1 and Tx2 (1985-93 and 1986-95 resp.) CyA (subgroup CC). Compared was survival of grafts by the actuarial method (with regard to all losses regardless of cause) by the end of the 4th year inside the subgroups (Tx2, vs. Tx1 and Tx3 vs. Tx2 in the same subjects) and between subgroups (Tx1 vs. Tx1 and Tx2 vs. Tx2 in different subjects). Moreover in paired investigations the survival of recipients and grafts after Tx2 was compared after immunosuppression on the basis of CyA with the same parameters after Tx1 in different subjects with the same immunosuppression, operated at approximately the same time (n = 81) and survival of subjects with Tx1 + Tx2 on the CC regime regardless whether the second grafts functioned at the time of the last examination, with survival of subjects after Tx1 where after graft failure Tx2 was not performed (n = 34). Prophylaxis with antilymphocyte globulins was not used. Survival of second and first grafts did not differ in any of the subgroups, third grafts survived at the end of the third year more frequently than second grafts (66 vs. 18%, p < 0.01). Second grafts in CC survived more than in AA (55 vs. 28%, p < 0.01). In the paired study Tx2 vs. Tx1 the survival of grafts and recipients was the same (88 vs. 89%, N.S. and 47 vs. 62% resp.), in the paired study Tx1 + Tx2 vs. Tx1 more subjects with Tx1 + Tx2 survived 10 years after Tx1 than subjects who did not have Tx2 (82 vs. 49%, p < 0.05).

CONCLUSIONS

A further transplantation of the kidney after functional loss of the first graft is the method of choice: the mortality is low, the probability of several years' function is considerable and the prognosis as regards quality and length of life better than with regular dialysis treatment.

[A single-center controlled clinical study with Sandimmune Neoral after kidney transplantation]

The authors compared in a controlled clinical study two groups of patients after a first renal transplantation treated by triple drug immunosuppressive therapy. In a group of 31 patients the triple combination comprised Sandimmune Neoral. In the control group there were 30 patients who received Sandimmune. No differences were found between the two groups as regards the effectiveness of this treatment and the authors did not confirm a lower incidence of rejections described in patients treated with Sandimmune Neoral. They confirmed, however, a lower interindividual variability of Cy-A levels assessed specifically in patients treated with Sandimmune Neoral.

[Conversion of cyclosporin A therapy to conventional treatment with diagnostic use of aspiration biopsy in kidney transplantation]

BACKGROUND

Withdrawal of cyclosporin-A from maintenance immunosuppressive therapy involves risk of rejection. The aim of the study was to reduce the risk of rejection and to evaluate the fine-needle aspiration biopsy in predicting rejection.

METHODS AND RESULTS

In 41 patients 14.4 +/- 2.6 months after the first transplantation of a cadaveric graft with good and stabilized function, cyclosporine was withdrawn from triple-drug therapy while the doses of azathioprine and prednisone were increased. Prior to the change fine-needle aspiration biopsy (FNAB) was performed and methylprednisolone 500-250-250 mg administered in 3 days. FNAB was repeated after 2 weeks. 39 patients fulfilling inclusion criteria but ineligible for the switch for different reasons served as a control group. Both groups were comparable in demographic and immunological parameters. Within 3 months after conversion, rejection was observed in 3 patients (7%) vs 2 patients (5%) of the control group over a comparable period of time: and within 6 months in 6 patients (15%) and 3 patients (8%) respectively (NS). No relationship between rejections before and after conversion was found. FNAB appeared to have some predictive value for rejection. In all of the 3 patients experiencing rejection, a rejection pattern was present in the 2nd biopsy.

CONCLUSIONS

Incorporation of methylprednisolone into conversion therapeutic regime decreased the risk of rejection to 7%. The rejection pattern in the second FNAB after methylprednisolone administration may be predictive for further rejection development.

Prophylaxis of acute gastroduodenal bleeding after renal transplantation

Severe gastroduodenal bleeding after renal transplantation is effectively prevented by H2 receptor blockers. New drugs for prophylaxis include proton pump inhibitors. The aim of the present study was to compare the effects of prophylaxis with the H2 blocker ranitidine and with the proton pump inhibitor omeprazole. One hundred seventy-seven consecutive patients were included in a controlled, prospective, randomized study after cadaveric renal transplantation. In one case, ranitidine failed to prevent exsanguination due to duodenal peptic ulcer bleeding. No bleeding was noted in the omeprazole group. There were no significant differences between the groups in hospitalization time, development of renal function, amount of cyclosporin A, prednisone, azathioprine, or methylprednisoline ingested, or laboratory biochemical parameters. We conclude that prophylaxis of severe gastroduodenal bleeding after renal transplantation with omeprazole is effective. Omeprazole is certainly as good as ranitidine; its advantages are a prolonged effect and a simple dosage, independent of graft function development.

[Early changes in vascular graft rejection in transplanted kidneys: the past and the present]

BACKGROUND

With maintenance azathioprine+prednisone and in biopsies performed exceptionally earlier than in the 4th week (1966-1984, 476 cadaveric kidney transplantations), prevalence of obliterative arteriopathy (OA, transmural arteritis, 4/III/v3 Banff classif.) was 22.1%, with graft loss by rejection within 6 mos. in 89.4%. The aim of this analysis was to study prevalence and prognostic importance of the former and of further early vascular lesions in subjects with maintenance cyclosporin A using biopsies performed as early as in the 1st week.

METHODS AND RESULTS

In a retrospective study on 449 transplantation (1987-92, cyclosporin A+prednisone+azathioprine, 64.7% grafts histologically--mostly repeatedly--examined), prevalence and prognostic classification (A-good, B-uncertain, C-poor prognosis) in recipients with OA, with cellular arteriopathy (CA, intimal arteritis, 4/II-III/v2-v3 Banff classif.) and with minimal arterial lesions (MZ) were assessed. Prevalence of OA was found to be 7.1% transplantations, with graft loss by rejection within 6 mos. in 71.9%, and with A:C proportion 25.0%: 62.5%. CA was found in 5.1% and showed A:C proportion 34.7%: 34.7%; in 6/13 cases with repeated histology, OA was later encountered, which is a strong point against its humoral pathogenesis. Prevalence of MZ was 10.9%, with A:C proportion 40.8: 4.1%.

CONCLUSIONS

Both OA and CA are related to rejection, while the etiology of MZ remains to be clarified. With cyclosporine, prevalence of OA markedly decreased and its prognosis somewhat improved; secondary prevention is possible when an early diagnosis (early and repeated biopsies) is done and immediate treatment (antilymphocyte globulins) started.

[Kidney transplantation and tumors]

BACKGROUND

In conjunction with organ transplantation and subsequent treatment there is a number of influences which potentiate the development and possibly the growth of tumours. This applies naturally also to transplantations of the kidneys. The objective of the present study was to assess the frequency and type of tumours in patients after renal transplantation and compare these results with data of the at present most extensive worldwide register in Cincinnati (CTTR).

METHODS AND RESULTS

The authors analyzed a group of 879 patients where within the period between March 21, 1966 and Sept. 29, 1992 a total of 989 renal transplantations were performed from dead relations-934 or from living relations (55); in 38 patients combined transplantations of kidney and pancreas were performed. The group comprised 59% men and 41% women. In the course of years the pattern of prophylactic immunosuppression changed: up to 1984 the basic drug was azathioprin combined with prednisone, during the same year cyclosporin A was introduced as a rule in a triple combination with azathioprin and prednisone; less frequent was the combination of cyclosporin A and prednisone. For antirejection treatment corticoids were used, later supplemented with polyclonal or monoclonal antibodies. During the period 1966-1992 tumourous diseases were diagnosed in 32 patients (3.64%); in two of these patients; combined transplantation of the kidney and pancreas was performed (5.3%). There was no difference in the frequency of tumours in patients with immunosuppressive medication (azathioprin with prednisone-3.80%) and cyclosporin A (3.51%). The mean age of the patients at the time of diagnosis of the tumour was 50.2 years, the interval after transplantation was 42.2 months (in patients treated with azathioprin 57 months, in the group treated with cyclosporin A 29.2 months). As far as the location of tumours is concerned, tumours of the skin predominated 25% (as compared with CTTR where it was 30%), tumours of the patient's own kidneys 21.9% and of the urinary pathways 15.6%, tumours of the gastrointestinal tract 12.5%, lymphomas in 9% (as compared with 15-20% in CTTR), tumours of the lungs 6.25% and other localizations also 6.25%. Some tumours frequently encountered in the population (lung cancer, cancer of the prostate, breast, colorectal carcinoma) are less frequent in patients after transplantation (CTTR); however, this fact was not confirmed by the authors. In renal tumours and tumours of the efferent urinary pathways data on analgetic nephropathy were encountered very frequently.

CONCLUSIONS

The prevalence of tumours of various organs in patients after transplantations of the kidneys are not a frequent but a very serious complication. Its causes are multifactorial. The group after renal transplantations in the Czech Repubic has some deviations as compared with CTTR as regards affection of organs.

[Urea clearance and measurement of glomerular filtration in patients with chronic renal insufficiency]

In 31 patients with chronic renal insufficiency (CHRI) the authors investigated the relationship between insulin or polyfructosan S (CPFS) clearance, urea clearance (Curea) and creatinine clearance (Ccr). The mean clearance values of these substances were as follows: CPFS: 0.198 (+/- 0.091) ml/s, Curea: 0.183 (+/- 0.086) ml/s, Ccr: 0.315 (+/- 0.169) ml/s. Between the values of Curea and CPFS, similarly as between values of Ccr and CPFS, a significant linear relationship was revealed, however, the regression line indicating the relationship between Curea and CPFS was closer to the identity line than the relationship between Ccr and CPFS. The results suggest that in patients with CHRI (where CPFS less than 0.4 ml/s) Curea is close to the value of glomerular filtration.