Agonal phase,ischaemic times,and renal vascular abnormalities and outcome of cadaver kidney transplants.

A retrospective study of 250 cadaver kidney transplants was carried out to determine the effects of the agonal period, the warm and cold ischaemic times, and the use of kidneys with vascular anomalies on the primary success and failure and the subsequent level of function of the transplants. Kidneys with vascular anomalies or from non-ventilated donors had a primary failure rate of over 30%, whereas those with normal vasculature or from ventilated donors had a rate of 17%. An initial warm ischaemic time of more than 60 minutes was associated with a primary failure rate of 57% and a cold ischaemic time of over 550 minutes with a primary failure rate of 47%. The interrelationship between the warm and cold ischaemic times in the primary success or failure of the transplants was examined and criteria defined for selecting potentially viable cadaver kidneys for transplantation, as follows: (1) The donor should be (a) ventilated, (b) aged 6-50 years, and (c) have normal ante-mortem renal function and have secreted more than 1-5 1 of urine in the 24 hours before death (or an equivalent volume if the urinary output was recorded for less than 24 hours before death); (2) the kidney should have normal renal vasculature enabling single arterial and venous anastomoses to be performed; (3) kidneys with I.W.I.T.s of longer than 60 minutes should not be used; (4) for kidneys with I.W.I.T.s of less than 20 minutes the C.I.T. is not critical but should not exceed 12 hours; (5) for kidneys with I.W.I.T.s of 20-60 minutes the C.I.T. should not exceed 450 minutes.     

Vertical mammaplasty: early complications after 250 personal consecutive cases.

No surgeon likes to face complications. It takes effort to treat them personally and more effort to note, count, analyze, and demonstrate them. The author carefully followed 250 personal consecutive patients (476 breasts) who underwent vertical mammaplasties between 1990 and 1998; studying the complications and their relationship with the types of breasts and patients was very instructive. The main observations from this study follow. The most frequent benign complication was seroma (5 percent of breasts), which usually required one or two aspirations after surgery. Hematomas occurred in six patients (1.2 percent of breasts), who had all had mastopexies. Hematomas required immediate surgical evacuation. The major complication of breast reduction, i.e., areola necrosis, was rare (only two partial necroses occurred), but it left deformities that were difficult to correct. Infection without tissue necrosis was rare (two cases), and healing complications happened in only 5.4 percent of all cases. Healing complications were directly related to the size and fat content of the breasts. None occurred in mastopexy cases. For reductions, delayed skin healing was observed in 5 percent of cases and delayed breast tissue healing in 3 percent of cases. More healing complications occurred after liposuction of the breast, which was performed in the more fatty breasts. Delayed healing of skin and breast tissue was bothersome because healing was slow, but it left only a moderate deformity. In cases of delayed healing, frequent dressings, rinsing the wound with antiseptic solutions, giving antibiotics if needed, and refraining from early surgical intervention are the keys to success. Good personal contact with the patient, especially if healing is slow, is the best way of helping her and avoiding aggressive attitudes. In conclusion, this survey revealed few complications; however, it does show that the risk of delayed and slow healing is greater in larger breasts. In obese patients, a simpler operation may be indicated, such as liposuction with skin reduction alone or a free nipple graft, as long as the patient is not motivated to obtain the best possible result.     

Fibronectin plasma levels after cadaver kidney transplantation

The fibronectin plasma levels of 17 patients undergoing cadaver kidney transplantation were determined serially in the postoperative course using laser nephelometry. While 9 patients retained their grafts (group A), the grafts of 8 patients had to be removed (group B), mainly due to rejection, 3 patients had severe infections. In both groups a significant drop of the plasma fibronectin occurred after surgery. There were no significant differences between the two groups in the mean fibronectin levels. After the initial drop the group A patients exhibited rising values leading to a stable level. Progressively declining fibronectin plasma concentrations were found in 2 of 3 severely infected patients. Fluctuating values were found in 3 group B patients without a clear correlation to the rejection crises or the kidney function. The data suggest that the fibronectin plasma level does not seem to be a prognostic marker for graft rejection. But it might be useful in the important and often difficult differentiation between rejection and infection.     

Aluminium accumulation and immunosuppressive effect in recipients of kidney transplants.

Aluminium that has accumulated in the body is thought to have a generalised cytotoxic effect. A prospective study of aluminium accumulation in bone-that is, subclinical aluminium toxicity--was carried out in 94 recipients of kidney allografts, who were followed up for three years. Subclinical aluminium toxicity was found in 66 patients. A significantly smaller proportion of patients with aluminium accumulation experienced a rejection episode: 30 (58%) nu 12 (86%) who received grafts from cadavers and 4 (29%) nu 10 (71%) who received grafts from living donors. On multivariate analysis only the source of the kidney and aluminium accumulation were found to influence the rejection rate. These findings suggest that aluminium accumulation has an immunosuppressive effect.     

Immunosuppressive drug-free operational immune tolerance in human kidney transplants recipients. Part II. Non-statistical gene microarray analysis

Kidney transplant is the reference treatment for patients with end-stage renal disease, but patients may develop long-term rejection of the graft. However, some patients do not reject the transplant, but instead are operationally tolerant state despite withdrawal of immunosuppressive treatment. In this second article we outline a microarray-based identification of key leader genes associated respectively to rejection and to operational tolerance of the kidney transplant in humans by utilizing a non/statistical bioinformatic approach based on the identification of "key genes," either as those mostly changing their expression, or having the strongest interconnections. A uniquely informative picture emerges on the genes controlling the human transplant from the detailed comparison of these findings with the traditional statistical SAM (Tusher et al. 2001 Proc Natl Acad Sci USA 98:5116-5121) analysis of the microarrays and with the clinical study carried out in the accompanying part I article.