bluuebunny/crossref_metadata_2025 huggingface dataset:
Nurses' Perspectives on Fostering Therapeutic Relationships While Working With Clients Who Display Conflict Behaviour
Authors: Overpelt Nick , Kool‐Goudzwaard Nienke , Stringer Barbara , van Meijel Berno
Published: September 2024

Therapeutic relationships are critical in the treatment of mental health disorders. Some clients experiencing mental health disorders display conflict behaviour—for example, suicidal or self‐harming behaviour, threats of or actual aggression, and various psychotic behaviours—which presents significant challenges for care professionals. In inpatient mental health units, where interactions with mental health nurses are frequent, managing conflict behaviour is crucial to maintaining care quality and fostering therapeutic progress. This study aims to describe nurses' perspectives on fostering therapeutic relationships while working with clients who display conflict behaviour. Qualitative research was conducted in a specialised treatment setting for such clients by means of individual semi‐structured interviews and a focus group interview with nurses. The results show that the nurses' primary focus is on cooperating with clients and colleagues. Regardless of conflict behaviour, nurses consistently invite clients to cooperate. To do so, they must manage their own emotions and expectations, emphasise the clients' responsibility and reduce the opportunities for conflict behaviour. The unit structure helps nurses by reducing ambiguity regarding treatment policies and inconsistencies in nurse–client interactions and allows nurses and clients to experience feelings of safety. To work with conflict behaviour, nurses need to feel valued and supported by their colleagues and have adequate time and resources. In conclusion, this study shows how nurses foster therapeutic relationships with clients who display conflict behaviour by focusing on cooperation, structure and safety.
Reasons Explaining High Emergency Department Use in Patients With Mental Illnesses: Different Staff Perspectives
Authors: Fleury Marie‐Josée , Ferland Francine , Farand Lambert , Grenier Guy , Imboua Armelle , Gaida Firas
Published: September 2024

For patients with mental illnesses (MIs), emergency departments (EDs) are often the entry point into the healthcare system, or their only resort for quickly accessing mental health treatment. A better understanding of the various barriers justifying high ED use among patients with MIs may help recommend targeted interventions that better meet their needs. This explorative qualitative study aimed to identify such barriers and the solutions brought forth to reduce ED use based on the perspectives of clinicians and managers working in EDs, other hospital departments or the community sector. Interviews were conducted between April 2021 and February 2022; 86 mental health professionals (22% were nurses) from four large urban ED sites in Quebec (Canada) were interviewed. Barriers were identified in relation to patient profiles, healthcare system and organisational features and professional characteristics. The key barriers that were found to explain high ED use were patients having serious MIs (e.g., psychotic disorders) or social issues (e.g., poverty), lack of coordination and patient referrals between EDs and other health services, insufficient access to mental health and addiction services and inadequacy of care. Very few solutions were implemented to improve care for high ED users. Better deployment of ED interventions in collaboration with outpatient care may be prioritised to reduce high ED use for patients with MIs. Improvements to the referral and transfer processes to outpatient care, particularly through care plans and case management programs, may be implemented to reduce high ED use and improve outpatient care among patients with multiple health and social needs.
Long‐term results of cyclosporine‐steroid therapy in 131 non‐matched cadaveric renal transplants
Authors: Gordon Robert D. , Starzl Thomas E. , Hakala Thomas R. , Taylor Rodney J. , Schroter Gerhard P. J. , Rosenthal J. Thomas , Weil Richard , Iwatsuki Shunzaburo , Carpenter Barbara J.
Published: September 2024

One‐hundred‐and‐twenty‐eight recipients of 131 consecutive, non‐matched cadaver renal allografts were treated with cyclosporine and steroids. They have been followed for 4 to 6 yr. Cumulative patient survival at 1‐yr was 92.2% and at 6yr it is 77.8%. Cumulative graft survival at 1‐yr was 79.4% and at 6 yr it is 50.0%. After the high‐risk 1st yr, the rate of graft loss was even and similar to that reported after the 1st yr for grafts treated with azathioprine and steroids. This indicates that cyclosporine nephrotoxicity has not had an obvious adverse effect on the survival of chronically functioning grafts. The results were better with primary grafting versus retransplantation, but were not significantly influenced by age, diabetes mellitus, or a delayed switch in patients from cyclosporine to azathioprine. We have concluded that cyclosporine‐steroid therapy is safe and effective for long‐term use after cadaveric renal transplantation.
Sequential – second and third – transplants in patients with heterotopic heart allografts
Authors: Novitzky D. , Cooper D. K. C. , Brink J. G. , Reichart B. A.
Published: September 2024

A second cardiac transplant has been performed in 8 patients who had previously undergone heterotopic heart transplantation (HHT); 2 subsequently required a third transplant. In 5 cases, the heterotopic donor heart was replaced, in 3 the recipient heart was replaced leaving the first donor heart in situ, and in 2 both hearts were excised and an orthotopic transplant was performed. Four patients have died between 24 days and 21 months following retransplantation, 3 remain alive and well at 25, 33, and 64 months after the second operation, and one at 4 months after a third procedure. From this small experience in patients with heterotopic heart transplants requiring retransplantation, we would recommend that the first heterotopic donor organ be left in situ, and the recipient's own heart should be replaced.
Total lymphoid irradiation in clinical kidney transplantation
Authors: Myburgh J. A. , Meyers A. M. , Botha J. R. , Thomson P. D. , Smit J. A. , Lakier R.
Published: September 2024

Total lymphoid irradiation was administered preoperatively to 37 patients receiving 38 kidney allografts. A basic dose of 800 cGy, was administered in twice weekly fractions of 60 to 100 cGy to a wide field. Follow‐up has ranged from I month to 5 years 8 months. Overall graft survival in 35 immunologically evaluable transplants (3 technical exclusions) is 89%. Actual 1‐yr graft survival for 17 patients at risk for this period is 88%, and 93% for 15 first cadaver grafts. Patient survival is 97%. All patients received low dose immunosuppressive drugs after transplantation, azathioprine and prednisone in 2, prednisone alone in 2 and cyclosporine (starting dose 6 mg/kg/day) and prednisone (20 mg/d) in 31. In 1 patient azathioprine and prednisone were withdrawn 3 yr after transplantation and graft function remains normal 2 yr 8 months later. Two further patients receive only small doses of prednisone (4 and 5 mg/d) more than 2 yr after transplantation, after cyclosporine had been withdrawn approximately 2 months postoperatively. Mean serum creatine is 123 ± 45 μlmol/l, and all but 2 patients have values <200 μmol/l. Over one half of the patients have never experienced any rejection episodes. When these have occurred they have been readily reversible except in 3 instances. Infective complications have been uncommon. Wide field, low dose total lymphoid irradiation in this center has resulted in better graft and patient survival, and better graft function than in patients not receiving it. It has permitted the use of substantially lower doses of immunosuppressive drugs, and infective complications have been rare. Transplantation tolerance appears to have resulted in 1 patient thus far, and may also have developed in 2 further patients.
Treatment of aplastic anemia with marrow grafts from related donors other than HLA genotypically‐matched siblings
Authors: Beatty Patrick G. , Di Bartolomeo Paolo , Storb Rainer , Clift Reginald A. , Buckner C. Dean , Sullivan Keith M. , Donoy Kristine , Appelbaum Frederick R. , Anasetti Claudia , Witherspoon Robert , Sanders Jean , Stewart Patricia , Martin Paul J. , Ciancarelli Marina , Hansen John A. , Thomas E. Donnall
Published: September 2024

24 patients with severe aplastic anemia were given marrow grafts from related donors other than HLA‐identical siblings. 2 patients received cyclophosphamide (CY) plus total body irradiation (TBI) as part of their preparative regimen. The remaining 22 received CY only, with or without other immunosuppressive agents. All donor/recipient pairs were genotypically identical for one HLA haplotype and had variable numbers of similar antigens on the unshared haplotypes. 6 patients received marrow from donors who were HLA‐A, B, DR, Dw phenotypically matched. All 6 are currently engrafted and surviving, 3 after having had Acute Graft‐Versus‐Host Disease (AGVHD) and 4 with Chronic Graft‐Versus‐Host‐Disease (CGVHD). The remaining 18 patients received HLA partially‐incompatible grafts. Of 17 partially‐matched patients evaluable for engraftment, 10 had failure of engraftment or graft rejection; all died of infectious complications. Of the 7 mismatched patients achieving sustained engraftment, all developed grade II–IV AGVHD. 6 of 11 patients who survived more than 100 d after transplant had CGVHD. Currently, 2 of 18 patients who were mismatched for 1 or more loci survive with hematological recovery. This study shows that patients with refractory severe aplastic anemia who have a phenotypically‐matched donor clearly benefit from a marrow transplant using only CY for conditioning. Those with partially‐matched donors are at high risk for graft rejection and may need additional immunosuppression such as CY plus TBI to facilitate engraftment. For those who engraft, more effective prophylactic and/or treatment measures for AGVHD are needed to improve survival.
Biliary tract complications following orthotopic liver transplantation
Authors: Vicente Emillio , Perkins James D. , Sterioff Sylvester , Kiely Michael , Rakela Jorge , Krom Ruud A. F.
Published: September 2024

Biliary tract complications are a significant risk following orthotopic liver transplantation (OLT). We reviewed the biliary tract complications of the first 50 liver transplants in 44 recipients performed in our institution. The mean follow‐up was 8 months (range 1 to 16 months). Biliary tract complications that required surgical or instrumental intervention developed in 17 of the 50 (34%) transplants. No deaths were attributable to biliary tract complications. Hepatic artery thrombosis caused the biliary tract complication in 3 transplants (1 stenosis, 2 anastomotic leaks) and a cystocele of the cystic duct remnant caused 1 common bile duct obstruction. The other 13 complications were associated either with the type of anastomosis performed or type of stent used. An end‐to‐end choledochocholedochostomy was performed in 31 transplants and 2 developed biliary tract complications (6.5%). One developed a biliary leak and the other developed a stenosis at the anastomosis. Nineteen of these choledochocholedochostomies were stented with a straight tube and 6 developed stent‐related complications. Twelve were stented with a T‐tube and only 1 stent complication occurred. An end‐to‐side choledochojejunostomy with a Roux‐en‐Y loop was performed in 19 patients. Only 1 early biliary complication occurred (5%), which was an anastomotic leak. However, 2 developed a stenosis of the entire donor extra‐hepatic duct, 12 and 13 months following transplantation. All anastomoses were stented with a straight tube and only 1 leak developed at the entrance site of the stent into the Roux‐Y. We conclude that the choledochocholedochostomy and the choledochojejunostomy with a Roux‐en‐Y loop are safe methods of biliary reconstruction following OLT. We recommend that a T‐tube be used for stenting the choledochocholedochostomy, and a hepatic artery thrombosis must be excluded when biliary tract complications develop.
Non‐invasive parameters for detection of cardiac allograft rejection
Authors: Haverich Axel , Kemnitz Josef , Fleguth Hans‐Gerd , Wahlers Thorsten , Schäfers Hans Joachim , Herrmann Gunhild , Schröder Hans‐Joachim , Wonlgeit Kurt , Maisch Bernhard , Gratz Klaus Friedrich , Borst Hans Georg
Published: September 2024

Six non‐invasive parameters for detection of allograft rejection were evaluated in a series of 51 consecutive heart transplant recipients. All patients were treated with a triple‐drug regimen for immunosuppression, consisting of steroids, azathioprine and cyclosporine A. Three immunological and three functional parameters were compared with the results of endomyocardial biopsies (EMB). The number of activated lymphocytes in the peripheral blood was assessed by cytoimmunological monitoring (CIM) and correlated with EMB in 727 instances. In 154 of these, acute rejection was present, the sensitivity of CIM was 74.1%. Serum neopterine levels were assessed in 246 samples, 56 of which were obtained during acute rejection. The sensitivity of this assay was 50%. Antimyolcmmal antibodies (AMLA) were studied in 89 blood samples. Correlation with acute rejection on EMB disclosed a sensitivity of 67% for IgM and 65% for IgG subclasses of AMLA. Of the functional parameters studied, both intramyocardial electrogram (telemetry pacemaker system), and left ventricular ejection fraction (radionuclide ventriculography) showed poor correlations with EMB (47% and 39%, respectively). M‐mode echocardiography, by contrast, more reliably predicted acute rejection when assessing the isovolmetric relaxation period (sensitivity 78%). With the combined use of CIM and echocardiography, no acute rejection was missed in 9 instances (sensitivity 100%). It is concluded that more than one non‐invasive parameter is needed to accurately predict cardiac allograft rejection. The combined use of functional and immunological parameters appears advantageous.
Intrarenal pressure and renal transplant survival
Authors: Salaman J.R. , Ross W.B. , Griffin P.J.A. , Williams J.D.
Published: September 2024

Intrarenal pressure was monitored regularly during the first 3 weeks after transplantation in 110 patients who had received cadaveric renal transplants. A rise in intrarenal pressure to 40 mmHg or above was noted in 54 patients, 49 of whom (91%) were confirmed as having rejection. The remaining 56 patients registered a normal intrarenal pressure (less than 40 mmHg) although in 5 (9%) the presence of rejection was missed. The patients have been followed up for 3 to 5 years. Graft survival after 1 month was significantly worse in the group registering a high pressure, the difference being due to an excess of kidneys being lost from rejection. Graft losses after 1 month were not affected. We conclude that a raised intrarenal pressure early after transplantation gives an accurate diagnosis of rejection and that kidneys registering such a rise are less likely to survive.
Relative risk of donor‐transmitted Toxoplasma gondii infection in heart, liver and kidney transplant recipients
Authors: Speirs G. E. , Hakim M. , Calne R. Y. , Wreghitt T. G.
Published: September 2024

Primary Toxoplasma gondii infection in immunocompromised patients may have devastating consequences. There are more reported cases of fatal donor‐acquired T. gondii infections in kidney than in heart or liver transplant recipients. This has produced a biased view of the true situation with regard to infection risk, principally because there have been many more kidney than liver or heart transplants performed. We have therefore studied the relative impact of donor‐acquired T. gondii infection in heart, liver and kidney transplant recipients in our center. We assessed 151 heart, 39 liver and 100 kidney transplant recipients and found 14.5% heart, 13.2% liver and 20% kidney transplant recipients were mismatched for T. gondii. The results show that, in our center, the risk of seronegative recipients acquiring primary T. gondii infection from a seropositive organ donor is greater in heart (57%) than in liver (20%) transplantation. No evidence of donor‐transmitted T. gondii in kidney transplant recipients was observed in this study. We have therefore shown the relative risk of donor‐acquired T. gondii infection in heart, liver and kidney transplantation in our center.
HLA‐identical sibling renal transplants: No rejections with a cyclosporine‐azathioprine‐prednisone protocol
Authors: Chan Gary L. C. , Canafax Daniel M. , Ascher Nancy L. , Dunn David L. , Payne William D. , Fryd David S. , Noreen Harriet , Sutherland David E. R. , Simmons Richard L. , Najarian John S.
Published: September 2024

Despite the superior patient and allograft survival rates of HLA‐identical sibling renal transplantation, a substantial incidence of acute rejection still occurs with the conventional azathioprine‐prednisone (AZA‐P) or AZA‐P‐antilymphocyte globulin (ALG) immunosuppressive regimens. In an attempt to further improve these results, we compared a cyclosporine (CSA)‐AZA‐P combination with AZA‐P‐ALG in 60 consecutive HLA‐identical sibling renal allograft recipients. The distribution of gender, age and proportion of diabetics was almost identical between the two groups. There was no significant difference (p = 0.51) between the CSA‐AZA‐P versus AZA‐P‐ALG groups in patient or graft survival at 1 year (100% versus 93%). Renal function was also similar when comparing the best (1.0 ± 0.7 vs 1.0 ± 0.3 mg/dl, p = 0.46) and current serum creatinine concentrations (1.4 ± 0.7 vs 1.4 ± 0.3 mg/dl, p = 0.45). The AZA‐P‐ALG treated group had a 40% incidence of rejections at 6 months, while rejections were totally eliminated in the CSA‐AZA‐P group (p < 0.001). Patients who received CSA‐AZA‐P also had a lower incidence of infections at 6 months posttransplant (3% vs 27%, p = 0.05), and shorter mean hospitalization time posttransplant (7.4 ± 4.3 days vs 12.4 ± 7.7 d, p < 0.001). Our results suggest that the CSA‐AZA‐P combination is safe and extremely effective for immunosuppression in HLA‐identical sibling renal transplantation.
Cyclosporine blood levels in diltiazem‐treated kidney graft recipients
Authors: Walz Gerd , Kunzendorf Ulrich , Keller Frieder , Neumayer Hans‐H. , Offermann Gerd
Published: September 2024

Ciclosporin (CsA) blood trough levels were measured with three different radioimmunoassays (RIAs) and high performance liquid chromatography (HPLC) in 16 patients after cadaver kidney transplantation. All patients had been treated with CsA and low‐dose steroids, while 8 patients additionally received diltiazem, a calcium channel blocking agent. Almost identical values were measured for CsA in patients treated with CsA and steroids, by either HPLC or RIA, using a monoclonal antibody specific against unchanged CsA (sAB). In routine measurement, using polyclonal sheep antibodies (PSA), CsA levels were found to be 75% of the CsA levels measured by an unspecific monoclonal antibody (uAB). However, simultaneous application of diltiazem led to a significant increase of CsA (as measured by sAB and PSA) (p < 0.05), while no significant change was detected using uAB and HPLC. Since CsA measured by PSA rose to 96% of CsA measured by uAB and linear function of CsA levels measured by HPLC and sAB attribute this to a higher background, it may be concluded that diltiazem changes CsA metabolite concentrations and is influencing cross‐reactivity of the specific monoclonal antibody, rather than directly affecting the levels of unchanged CsA.
Serum thymidine kinase, CMV‐specific antibodies and total immunoglobulins in renal transplant patients during immunosuppression with cyclosporine A
Authors: Gronowitz J. S. , Tötterman T. H. , Källander C. F. R. , Hagström Å. , Tufveson G.
Published: September 2024

The levels of serum thymidine kinase (S‐TK), total IgG, and IgG‐ and IgM‐type antibodies towards cytomegalovirus (CMV) were regularly monitored before and up to half a year post‐transplantation in 24 renal allograft recipients treated with cyclosporine A plus prednisolone. The CMV serology showed that 6 patients had primary infection, while at least 13 had reactivation of the virus. Only 2 patients, one of whom had recurrent infection, had clinical CMV disease. Elevated S‐TK levels up to 150 units were found to precede the increase in anti‐CMV IgG. With 2 exceptions, anti‐CMV IgM was found only in the patients with primary infection. The S‐TK peak related to the increase in anti‐CMV IgG occurred in the majority of the patients with recurrent infection during the first 2 weeks, while 2 of the patients with primary infection had their major S‐TK activity between day 30–60. Additional smaller S‐TK increases were registered after administration of corticosteroids because of rejection. As low S‐TK levels were mostly found before the corticosteroid administration, it was concluded that rejection per se does not induce high S‐TK levels. High persistent S‐TK levels were seen only in the patients with overt CMV disease. Scrum total IgG showed huge increases mainly in patients with primary CMV infection. These increases were polyclonal, and significant increases in antibodies to multiple microbial antigens were more prevalent among patients with high increases in the total IgG level. Cytotoxic antibodies to donor lymphocytes were, however, not detected. It is concluded that S‐TK is a useful marker for monitoring CMV disease. The implication of the polyclonal Ig induction on the use of serological tests as well as the possible mechanism of its induction are discussed.
Expression of class II antigens on T lymphocytes during cyclosporine immunosuppression for kidney transplantation
Authors: Hayes Joseph M. , Valenzuela Rafael , Novick Andrew C. , Steinmuller Donald R.
Published: September 2024

Since peripheral blood T lymphocytes may express class II antigens during immunologic activation, we monitored 40 cadaveric renal allograft recipients treated with cyclosporine. Peripheral blood T lymphocytes were monitored by flow cytometry for expression of DR antigen after transplantation and during rejection. Patients were treated with an ALG/CsA‐based sequential immunosuppressive protocol. All patients exhibited an early post‐transplantation increase in the percentage of HLA‐DR antigen expression on peripheral blood T lymphocytes (p < 0.001; Student's t‐test), with a gradual decrease 1–2 weeks after transplantation. In 14 of 16 patients with biopsy‐proven rejection, the percentage and the absolute numbers of T lymphocytes expressing HLA‐DR antigen increased significantly during rejection episodes (p < 0.001 and p < 0.001; Student's t‐test). In 13 of 16 patients who underwent biopsy‐proven rejection, a significant decrease was noted in the percentage and absolute numbers of T lymphocytes expressing HLA/DR– antigen 3 to 4 days prior to rejection (p < 0.001 and p < 0.001; Student's t‐test). Patients who did not undergo rejection episodes exhibited an early increase (p < 0.05; Student's t‐test) followed by a gradual decrease in DR expression on T lymphocytes. These values remained relatively stable (p = N.S.) thereafter in 8 of 12 patients. Two of 4 patients with symptomatic viral infections exhibited increased DR expression on peripheral T‐lymphocytes.
Renal cell carcinomas in renal allografts: A report of three cases
Authors: Bäckman Lars , Ringdén Olle , Lundgren Göran , Groth Carl‐Gustav
Published: September 2024

Three cases are described in which renal cell carcinomas occurred in renal allografts. In the first 2 cases, the renal cell carcinomas were found accidentally in the recipient room. The tumors were resected at the time of transplantation and the kidneys were left in place. The patients died 10 and 3 years after transplantation, respectively, with well functioning renal allografts and without any tumor manifestations. In the 3rd case, a renal cell carcinoma was found 3 yr after transplantation in a cadaveric allograft from a donor with a brain tumor. A transplantectomy was performed and the patient was regrafted after 1 yr and now has an excellent renal function and no signs of tumor manifestations.
OKT3 therapy in kidney, liver, heart, and pancreas transplantation
Authors: First M. Roy , Schroeder Timothy J. , Melvin David B. , Munda Rino , Fidler James P. , Balistreri William F. , Hurtubise Paul E. , Alexander J. Wesley , Penn Israel , Ryckman Fredrick C.
Published: September 2024

Orthoclone OKT3 was used 146 times in 123 transplant recipients to treat or prevent rejection. Reversal and prevention of rejection were evaluated at 1 week post‐treatment and at 1 year following OKT3 therapy, or at most recent follow‐up. Eighty‐one percent (73 of 90) of the rejection episodes in renal transplants were reversed with 67% of these grafts functioning at 1 yr at present. Eleven of 13 (85%) rejection episodes in cardiac transplant recipients were reversed, as were 18 of 20 (90%) hepatic transplant rejection episodes. Only 1 of 5 pancreas transplant rejection episodes was reversed. Thirteen high‐risk renal transplant recipients (PRA > 50% and a failed previous renal transplant), 4 cardiac transplant recipients, and 1 hepatic transplant recipient were treated with prophylactic OKT3; 8 of the renal, 3 of the cardiac, and the 1 hepatic transplants were functioning at 1 yr or at last follow‐up. Twenty‐three patients (14 kidney, 5 liver, 3 heart, 1 pancreas) were retreated with OKT3; reversal of rejection occurred in 87% (13 of 15) of patients with no antimurine antibodies, and in 83% (5 of 6) of patients with low antibody titer, but did not occur in the 2 patients with a high antibody titer. The mortality rate was 6.5% (8 of 123) in patients receiving OKT3. Overall, OKT3 is an effective agent in reversing and preventing rejection in solid organ transplantation with few severe side effects and a low mortality rate.
Prophylactic OKT3 and cadaveric renal transplantation at a single center
Authors: Shield Charles F. , Hughes John D. , Lemon Judy A.
Published: September 2024

The effectiveness of prophylactic OKT3 when compared to a standard triple‐drug (cyclosporine, azathioprine, prednisone) regimen to decrease the number and severity of rejection episodes, ATN, and to improve the quantitative and qualitative allograft function in cadaver renal transplantation was studied. The patients with no. single, or multiple rejection episodes were significantly different between the groups, with the majority of the OKT3 patients having none or a single rejection episode (χ2 = 3.86 p < 0.05). The quantitative allograft function was not different between the groups. However, the OKT3 patients had a better qualitative function at all time periods with a mean serum creatinine of 1.5 ± 0.3 in the OKT3 arm and 2.5 ± 1.2 in the standard arm at 1 year. Eighty percent of patients with PRA > 50%. treated with OKT3, and followed for at least 1 yr had functioning allografts with excellent serum creatinines. The prophylactic use of OKT3 did not increase infectious complications. The ATN rate and duration was similar between groups. Antimouse antibody production after the initial course of OKT3 was similar. No patients needing retreatment with OKT3 were prevented from receving this therapy because of previous antibody production.
Use of fine needle aspirates to monitor the treatment of acute renal allograft rejection
Authors: Ubhi Charanjeit S. , Baker Jennifer M , Guillou Pierre J , Giles Geoffrey R.
Published: September 2024

Forty‐five renal allograft recipients immunosuppressed with cyclosporin have been monitored by fine needle aspiration cytology (FNAC) during anti‐rejection therapy with either a 3‐ or 5‐day course of IV methylprednisolone (IVMP). FNAC performed after 3 d of IVMP correctly identified 19 of the 27 patients who required additional immunosuppression (sensitivity 70.3%), and 17 of the 18 patients who did not require any further therapy for rejection (specificity 92.9%). An initial 5‐d course of IVMP did not decrease the requirements for additional immunosuppression. We suggest that FNAC monitoring may provide an objective approach to management of anti‐rejection and maintenance immunosuppressive therapy.
Multiple risk factor analysis of non‐immunological delayed graft function after kidney transplantation
Authors: Meurisse M. , Albert A. , Defraigne J. O. , Bonnet P. , Honore P. , Pirenne J. , Henrivaux P. , Mahieu P. , Beaujean M. A. , Limet R. , Jacquet N.
Published: September 2024

With the advent of cyclosporine‐A immunotherapy during the initial post‐transplantation period, many factors which govern the donor allograft, organ procurement and recipient host have become more important for avoiding or reducing the incidence of non‐immunological delayed graft function. We analyzed data collected from 61 consecutive cadaver kidney transplantations and applied a multivariate stepwise logistic regression analysis to 11 risk factors recorded from donor and recipient patients during the critical pre‐ and immediate postoperative period. Among the variables studied, four risk factors were selected, which jointly provide optimal prediction of immediate renal allograft function. These are dopamine donor management, immunosuppressive treatment, recipient mean pulmonary artery pressure and cold ischemia time. We determined a prognostic index and designed a table of probabilities of delayed graft function. Individual optimal strategies are suggested for the initial use of CsA which minimize its additive nephrotoxic side‐effect in the setting of a freshly transplanted cadaver kidney.
Hyperimmunoglobulin for cytomegalovirus prophylaxis following heart transplantation
Authors: Schäfers H.‐J. , Milbradt H. , Flik J. , Wahlers Th. , Fieguth H. G. , Haverich A.
Published: September 2024

Cytomegalovirus (CMV) disease remains an important cause of morbidity and mortality following organ transplantation. Since therapeutic possibilities in manifest clinical disease are limited, emphasis should be placed on preventive measures. In a retrospective analysis, 75 heart transplant patients given one of two protocols for prophylactic administration of CMV‐specific hyperimmunoglobulin were studied. The first group of patients received hyperimmunoglobulin on the operative and on the 10th postoperative day only. The second group received immunoglobulin on the operative day and then repeatedly with each treatment for graft rejection. Comparison of these two groups demonstrated that repeated prophylaxis limited the clinical severity of CMV infection and reactivation. Although the incidence of reactivation was unchanged, the incidence of primary CMV infection was reduced by repeated prophylaxis (5/8 vs. 7/25 patients; p = 0.06). We conclude that repeated administration of specific hyperimmunoglobulin with every period of increased immunosuppression has a beneficial effect on both CMV reactivation and infection following heart transplantation.
Posttransplant erythrocytosis and the risk of thromboembolic complications: Correlation from a prospective randomized study of cyclosporine versus azathioprine‐antilymphocyte globulin
Authors: Gruber Scott A. , Simmons Richard L. , Najarian John S. , Vercellotti Gregory , Ascher Nancy L. , Dunn David L. , Payne William D. , Sutherland David E. R. , Fryd David S.
Published: September 2024

To determine whether renal allograft recipients with sustained or transient elevation in hemoglobin (Hgb) level are at increased risk for thromboembolism, we examined the incidence of arterial and venous thromboembolic events in various subgroups of 224 patients who were prospectively randomized and stratified by risk to treatment with either cyclosporine‐prednisone (CSA‐P) (n = 117) or azathioprine‐prednisone‐antilymphocyte globulin (AZA‐P‐ALG) (n = 107). Eleven CSA patients (9.4%) and 4 AZA patients (3.7%) developed posttransplant erythrocytosis (PTE) (p = 0.08). There were no significant differences in the incidence of thromboembolic events among subgroups of phlebotomized or nonphlebotomized, CSA‐ or AZA‐treated, PTE patients, nor did these incidence rates differ significantly from those for the entire AZA and CSA groups. There was no significant increase in the incidence of thromboembolism in any of the CSA‐treated subgroups with “sustained” (≥ 1 year) or transient elevation in Hgb level when compared with the CSA‐P group as a whole or with CSA subgroups with lower Hgb levels. The percentage of AZA‐treated patients with thromboses increased in parallel with sustained Hgb levels, reaching statistical significance when patients with Hgb ≥ 16 g/dl for at least 1 yr were compared to the AZA‐P‐ALG group as a whole (p = 0.02), to AZA subgroups with lower Hgb levels (Hgb ≥ 14 g/dl for at least 1 yr, Hgb never > 17 g/dl, and Hgb never > 14 g/dl; p = 0.02, 0.02, and 0.05, respectively), and to their CSA‐treated counterparts (p = 0.03). Under both immunosuppressive regimens, however, Hgb levels tended to be low precisely at the time when patients in all subgroups had their complications. We conclude that neither transient marked elevations nor modest sustained elevations of Hgb level per se is directly associated with an increased incidence of thromboembolic complications in renal transplant recipients. PTE can be successfully managed without an increase in thromboses if therapeutic phlebotomy is utilized to maintain the hematocrit (HCT) < 50–55% and/or to treat symptoms attributable to polycythemia.
T‐cell depletion in bone marrow transplantation
Authors: Butturini Anna , Gale Robert Peter
Published: September 2024

T‐cell depletion can prevent graft‐versus‐host disease (GvHD) following bone marrow transplantation. Adverse consequences, however, including graft rejection and GvHD have been reported. We reviewed data from 36 trials of T‐cell depletion involving 924 transplant recipients worldwide. Results were compared with more than 3000 recipients of non‐T‐cell depleted grafts. These data indicate that T‐cell depletion reduced the incidence of GvHD from about 45% to about 10% in HLA‐identical transplants. However, the incidence of graft rejection increased from 1% to about 10%. The risk of leukemia relapse increased from about 15% to about 40%. Similar trends were observed for HLA‐nonidentical transplants. Thus, T‐cell depletion is effective in decreasing GvHD but is associated with adverse consequences including graft rejection and leukemia relapse. New approaches to the problems raised by T‐cell depletion are required for survival to improve.
Causes of death after liver transplantation in children treated with cyclosporine and steroids
Authors: Kahn Delawir , Esquivel Carlos O. , Makowka Leonard , Madrigal‐Torres Manuel , Yunis Eduardo , Iwatsuki Shunzaburo , Starzl Thomas E.
Published: September 2024

Two‐hundred‐and‐twenty‐seven children underwent orthotopic liver transplantation between March 1980 and March 1986. Seventy (31%) patients died during the study period. Four patients who died within 24 hours of the initial liver transplant and 5 patients who died outside of our institution were excluded from the analysis. Liver failure, related to either thrombosis of the hepatic artery, primary non‐function of the graft or rejection accounted for 25 of the remaining 61 deaths. In 21 patients death was related to overwhelming sepsis while 7 patients died from excessive bleeding. Eight of the deaths were due to a miscellaneous group of causes. Twenty percent of the 150 patients who received a single liver transplant died compared to a death rate of 50% in patients who underwent three transplants. Eighty‐five percent of the deaths occurred within 6 months after the initial liver transplant. Liver failure was the cause in the majority of the early deaths whereas the later deaths were more likely to be due to sepsis. This detailed analysis of the causes of death after pediatric liver transplantation in a large group of patients has revealed that advances in certain areas could lead to even better results.
Renal allograft failure from cholesterol emboli
Authors: Fischman Michael A. , Hancock Wayne , Bartus Stanley A. , Hull David , Schweizer Robert T.
Published: September 2024

Two recipients of cadaveric kidney transplants had graft failure due to cholesterol emboli. Two additional cadaver kidneys were found to have cholesterol emboli after procurement and were not transplanted. In both cases, the donor aorta was the probable source. Since cholesterol emboli may cause renal injury, care must be taken during donor nephrectomy to prevent such an occurrence.
The PACT: A rating scale for the study of clinical decision‐making in psychosocial screening of organ transplant candidates
Authors: Olbrisch Mary Ellen , Levenson James L. , Hamer Robert
Published: September 2024

Studied the reliability of clinical decisions regarding the acceptability of patients for heart and liver transplantation. 47 patients were interviewed by at least two clinicians who completed the PACT (Psychosocial Assessment of Candidates for Transplantation), a single page, 10 item rating scale. Interrater reliability was high (intraclass correlation = 0.85) with overall 96% agreement between raters on whether to transplant a given patient. Less than 5% of all pairs of ratings disagreed by more than one category. Partial correlations between individual items and final ratings ranged from 0.39 (drug and alcohol use) to 0.72 (personality and psychopathology). This scale will be a useful instrument for studying the pretransplant psychosocial evaluation process and will be helpful for learning how different programs weight various factors in selecting patients and how well these decisions predict clinical outcomes.
Cytomegalovirus infection after renal transplantation: Effect of prophylactic hyperimmunoglobulin
Authors: Kokado Yukito , Takahara Shiro , Ishibashi Michio , Tanaka Kazuko , Baba Koichi , Yabuuchi Momojl , Sonoda Takao
Published: September 2024

Cytomegalovirus (CMV) disease remains an important cause of morbidity and mortality following organ transplantation. In a retrospective analysis, 106 renal transplant recipients, immunosuppressed with cyclosporine, were studied. Thirty‐nine of these patients were administered CMV‐specific hyperimmunoglobulin. There were 61 instances of CMV infection within the first 3 months after transplantation. For patients whose rejection was treated with ALG or OKT3, the frequency of CMV infection was 76.9% (20/26) and was significantly higher than that for patients not administered either ALG or OKT3. The frequency of CMV infection remained unchanged, but the severity of CMV disease was reduced by prophylaxis. It is believed that repeated administration of CMV‐specific hyperimmunoglobulin after increased immunosuppression may have a beneficial effect on CMV infection following renal transplantation.
Cyclosporine pharmacokinetics in diabetic patients after kidney and pancreas transplantation
Authors: Lang J. , Garnier J. L , Faure J. L. , Dubernard J. M. , Faucon G. , Touraine J. L.
Published: September 2024

Adequate cyclosporine (Csa) therapy that avoids rejection and nephrotoxicity remains to be defined. We observed that diabetic patients submitted to combined renal and pancreatic transplantation required a higher dose of Csa than renal transplant recipients to obtain similar blood trough levels. We performed a pharmacokinetic study using HPLC to compare Csa metabolism in both groups and found that renal and pancreatic transplant recipients have an impaired gastro‐intestinal Csa resorption. Moreover, when those patients were reoperated, we observed a significant fall in Csa bioavailability. Whether this impaired Csa resorption is due to surgical procedures or to digestive tract abnormalities needs further investigation.
Lack of correlation between the DNCB skin test reactivity and renal transplant survival
Authors: Schaafsma M. R. , Stijnen Th. , van Es L. A. , Paul L. C.
Published: September 2024

The DNCB (2,4‐dinitrochlorobenzene) skin test is an in vivo test measuring delayed‐type hypersensitivity. Some previous studies have reported a predictive value of pre‐transplant DNCB skin testing on subsequent renal allograft survival. In this study, however, we could not find any difference in graft survival or in the number of rejection episodes between strong and weak responders to DNCB.
Early renal graft failure due to recurrence of Wegener's granulomatosis under cyclosporine therapy
Authors: Toussaint Charles , Thoua Yvette , Goldman Michel , Pauw Luc De , Catalano Carlo , Vereerstraeten Pierre
Published: September 2024

Recurrence of Wegener's granulomatosis led to loss of the graft within 34 days in a patient receiving cyclosporine. Review of the literature confirmed the rarity of recurrence of this disease after transplantation in azathioprine‐treated recipients, but this complication was recently described in 3 patients (including our case) who were on cyclosporine immunosuppression. Further experience will be needed to establish the optimal regimen for renal transplantation in patients with Wegener's granulomatosis.
Renal transplantation using a live donor with crossed renal ectopia
Authors: Schulak James A. , Kursh Elroy D. , Sedor John R. , Hricik Donald E.
Published: September 2024

We report a case in which an ectopic kidney was transplanted successfully from a 54‐year‐old woman to her 25‐yr‐old, hemodialysis‐dependent daughter with chronic interstitial nephritis. The donor had unfused crossed renal ectopia with her right kidney located in her left lower abdomen just below her normal kidney. Renal scintigraphy revealed normal excretory function and arteriography revealed a single artery and vein. The donor nephrectomy and recipient transplantation operation were uneventful and the recipient enjoys normal renal function 1 yr later.
Successful clinical small bowel transplantation: Report of a case
Authors: Deltz E. , Schroeder P. , Gebhardt H. , Gundlach M. , Timmermann W. , Engemann R. , Leimenstoll G. , Hansman M. L. , Westphal E. , Hamelmann H.
Published: September 2024

A case of allogeneic small bowel transplantation with living related organ donation in a 42‐year‐old patient is described. After the first operative step of heterotopic transplantation with two intestinal stomas, the graft was brought into continuity of the recipient's GI‐tract 6 weeks after transplantation. Immunosuppression was carried out by antithymocyte globulin, cyclosporin A and steroids. Two rejection episodes could be treated effectively with ATG and steroids respectively. Four months after the transplantation parenteral feeding could be stopped and, except for immunosuppressive drugs and fluid substitutions, complete oral nutrition is possible.
Immunosuppression for cadaveric renal allograft recipients: A risk‐factor matched comparison of the Minnesota Randomized Trial with an antilymphoblast globulin, azathioprine, cyclosporine, and prednisone protocol
Authors: Canafax Daniel M. , Min David I. , Gruber Scott A. , Matas Arthur J. , Payne William D. , Dunn David L. , Sutherland David E. R. , Simmons Richard L. , Najarian John S. , Fryd David S.
Published: September 2024

Our prospective, randomized trial comparing cyclosporine (CSA) and prednisone (P) with azathioprine (AZA)‐P‐antilymphoblast globulin (ALG) in cadaveric renal transplant patients from 1980 to 1984 demonstrated that CSA‐P treatment produced slightly higher graft survival rates, fewer acute rejection episodes, less infectious complications, and shorter hospital stays while the AZA‐P‐ALG treatment produced lower serum creatinine levels and a shorter duration of delayed graft function. In an attempt to capture the benefits of each protocol, we began evaluating a CSA‐P‐AZA‐ALG regimen in cadaveric renal allograft recipients. In this report, we compared the 1st year results of this new four‐drug protocol given to 78 patients with the 1st yr results of the two‐drug regimens previously studied (CSA‐P, n = 81 and AZA‐P‐ALG, n = 75). The three groups were matched for age, sex, number of retransplants, and diabetic status, and all patients were followed for at least 1 yr posttransplant. The overall 1‐yr actual patient survival rates were 94% for CSA‐P‐AZA‐ALG, 90% for CSA‐P, and 88% for AZA‐P‐ALG. Actual graft survival rates at 1 yr were 87% for CSA‐P‐AZA‐ALG, 80% for CSA‐P, and 73% for AZA‐P‐ALG. The incidence of acute rejection in the 1st yr was similar for CSA‐P‐AZA‐ALG ‐ and CSA‐P‐treated patients (40% vs 33%), but was lower in both of these groups than in the AZA‐P‐ALG‐treated patients (55%). The 1‐yr incidence of infectious complications was 38% for CSA‐P‐AZA‐ALG patients, 30% for CSA‐P patients, and 55% for AZA‐P‐ALG patients. Although the incidence of acute tubular necrosis was not significantly different among the three groups, the duration of oliguria and number of dialyses required were significantly less in the CSA‐P‐AZA‐ALG patients than in the CSA‐P patients. Serum creatinine levels at 1 yr posttransplant were lowest in the AZA‐P‐ALG patients (1.5 ± 0.2 mg/dl), 1.7 ± 0.2 mg/dl for CSA‐P‐AZA‐ALG patients, and 2.0 ± 0.2 mg/dl for CSA‐P patients. In summary, our CSA‐P‐AZA‐ALG immunosuppressive protocol for use in cadaveric renal transplantation has achieved its original goal of reducing the adverse consequences of CSA nephrotoxicity by decreasing the duration of acute tubular necrosis and improving creatinine levels while maintaining high patient and graft survival rates.
Diagnostic value of an immune monitoring program for the clinical management of immunosuppressed patients with septic complications
Authors: Volk Hans‐Dieter , Reinke Petra , Falck Peter , Staffa Gerhard , Briedigkeit Helga , v. Baehr Rüdiger
Published: September 2024

A serious complication in immunosuppressed patients (allograft recipients and patients with autoimmune diseases) is sepsis. Proceeding from cytofluorometric analyses of mononuclear blood cells, septic patients (n = 44) were found to fall into two categories: i) those with “immunoparalysis” (n = 22) which is defined as a drastic reduction of HLA‐DR+ monocytes (< 20%) and a variable decrease of the differentiation antigens on T lymphocytes, and ii) patients without "immunoparalysis" (n = 22). The HLA‐DQ antigen but not HLA‐class I antigen expression was also decreased on monocytes derived from septic patients with "immunoparalysis". In patients with "immunoparalysis" who were continued on immunosuppression, mortality was 90%! Mortality was 0% in those with "immunoparalysis" whose immunosuppression was rapidly tapered. The normalization of HLA‐DR antigen expression on monocytes and the appearance of activated T cells (commonly within 5–10 days after reduction of immunosuppression) indicate the recovery of the immune system and (in order to prevent a rejection) necessitate a return to routine immunosuppression. Using immune monitoring as a guide for immunosuppression, no rejection occurred in consequence of tapered immunosuppression. Septic patients without "immunoparalysis" had no mortality when they were maintained on routine immunosuppression. However, reduction of immunosuppression in this latter group provoked severe rejection crises. Our immune monitoring seems to be useful for the management of immunosuppression in patients with septic complications in order to minimize two risks, i.e. death by sepsis or loss of graft.
Comparison of UW with other solutions for liver preservation in dogs
Authors: Todo S. , Podesta L. , Ueda Y. , Imventarza O. , Casavilla A. , Oks A. , Okuda K. , Nalesnik M. , Venkataramanan R. , Starzl T. E.
Published: September 2024

The efficacy of the University of Wisconsin (UW) solution was compared with conventional Euro‐Collins solution, as well as with 3 variants of a silica gel solution developed at the University of Minnesota (UM). Protection of the liver grafts with UW was superior after 24 hour preservation, although the results were inferior to those with immediate transplantation, as judged by animal survival, liver function tests, coagulation, and histopathologic parameters. The UM‐III solution allowed similar animal survival as with the UW solution. Lactobionate and raffinose that are contained in both the UW and UM‐III solutions were thought to be essential constituents for long‐term preservation of liver grafts. The study not only establishes, under controlled circumstances, the superiority of the UW solution, but it also provides insight about the reasons for its effectiveness as well as a caution against its over exploitation.