Clinical Investigation

Kidney International (1985) 28, 178–186; doi:10.1038/ki.1985.138

Post-transplant acute renal failure in cadaver renal recipients treated with cyclosporine

Bruce M Hall1, David J Tiller1, Geoffrey G Duggin1, John S Horvath1, Annabelle Farnsworth1, James May1, James R Johnson1 and A G Ross Sheil1

1Renal Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, Australia

Correspondence: Dr B M Hall, Renal Transplantation Unit, Royal Prince Alfred Hospital, Missenden Road, Camperdown, N.S.W. 2050, N.S.W., Australia

Received 22 January 1984; Revised 7 February 1985.

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Abstract

Post-transplant acute renal failure in cadaver renal recipients treated with cyclosporine. The outcome of patients with acute renal failure following cadaveric renal transplant has been evaluated in a prospective, controlled trial, comparing treatment with cyclosporine (CSA) to prednisone, azathioprine, and antilymphocyte globulin (AZA). There was a high incidence of acute post-transplant renal failure in both groups: 37 of 51 CSA and 31 of 45 AZA patients, due to the long exposure of kidneys to warm and cold ischemia. Onset of adequate renal function was delayed for three or more weeks in 27 (53%) CSA and only nine (20%) AZA patients, and the only predisposing factor found was donor hypotension. All nine AZA and 18 of the 27 CSA patients with prolonged oliguria subsequently had a spontaneous diuresis. Nine of the CSA patients were changed to azathioprine and prednisone because of suspected CSA toxicity, and eight of these kidneys began functioning within days, even though they had been oliguric for 21 to 83 days. Of these nine patients, five had adequate long-term function on AZA, three developed CMV infections that were fatal to two individuals, and two rejected their grafts. Plasma CSA levels fluctuated widely in all patients, but were not higher in any group, including those with prolonged oliguria. During the oliguric period, biopsy specimens proved rejection was more common in the nine patients who had their CSA stopped than in the other CSA patients, and seven of these nine developed a diffuse interstitial fibrosis that was thought to be a manifestation of CSA toxicity.

Extensive analysis of the post-transplant course showed rejection and CSA nephrotoxicity as the only probable causes of the delayed recovery from oliguria in the CSA group. Although CSA-treated patients tended to have higher serum creatinines, no significant differences were found at 12 months in any of the groups. Overall graft survival was similar in all groups.

Insuffisance rénale aiguë post-transplantation chez des receveurs de rein de cadavre traités par la cyclosporine. L'évolution de l'insuffisance rénale aiguë chez des malades après transplantation de rein de cadavre a été évaluée par un essai prospectif contrôlé, comparant un traitement par cyclosporine (CSA) à la prednisone, l'azathioprine, et les globulines antilymphocytaires (AZA). Il y a eu une forte incidence d'insuffisance rénale aiguë post-transplantation dans les deux groupes: 37 malades des 51 CSA et 31 des 45 AZA, en raison de l'exposition prolongée à l'ischémie chaude et froide. L'apparition d'une fonction rénale correcte a été retardée de trois semaines ou plus chez 27 (53%) malades CSA et chez seulement neuf (20%) AZA, et le seul facteur prédisposant trouvé a été l'hypotension du donneur. Les neuf malades AZA et 18 des 27 CSA présentant une oligurie prolongée ont ensuite eu une diurèse spontanée. Neuf des malades CSA ont été changés pour de l'azathio-prine et de la prednisone en raison d'une suspicion de toxicité CSA, et huit de ces reins ont commencé à fonctionner en quelques jours, bien qu'ayant été oliguriques pendant 21 to 83 jours. De ces neuf malades, cinq ont eu une fonction à long terme correcte sous AZA, trois ont développé des infections à CMV qui ont été fatales chez deux malades, et deux ont rejecté leur greffon. Les niveaux plasmatiques de CSA ont largement fluctué chez tous les malades mais n'étaient pas plus élevés dans un des groupes, y compris ceux avec oligurie prolongée. Pendant la période oligurique, un rejet prouvé par biopsie était plus commun chez les neuf malades qui avaient eu leur CSA arrêtée, que chez autres malades CSA, et sept de ces neuf ont développé une fibrose interstitielle diffuse qui a été supposée être une manifestation de toxicité de la CSA.

Une analyse extensive de l'évolution post-transplantation a identifié le rejet et la néphrotoxicité CSA comme seules causes probables du retard de récupération de l'oligurie dans le groupe CSA. Bien que les malades traités par CSA tendaient à avoir des créatinines sériques plus élevées, aucune différence n'a été trouvée à 12 mois dans aucun des groupes. La survie globale du greffons était identique dans tous les groupes.

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