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. 1964 Sep:61:470-97.
doi: 10.7326/0003-4819-61-3-470.

RENAL HOMOTRANSPLANTATION; LATE FUNCTION AND COMPLICATIONS

T E STARZL, T L MARCHIORO, K A PORTER, C A MOORE, D RIFKIND, W R WADDELL

RENAL HOMOTRANSPLANTATION; LATE FUNCTION AND COMPLICATIONS

T E STARZL et al. Ann Intern Med. 1964 Sep.
No abstract available

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Figures

FIGURE 1
FIGURE 1
Course of Patient LD 6, who received a homograft from his younger brother on April 17, 1963. Both were O blood type. Thymectomy was carried out 26 days before transplantation. Splenectomy and right nephrectomy were performed at the same time as homotransplantation; the left kidney was removed 1 week later. A rejection crisis that occurred 18 days postoperatively was reversed with prednisone and actinomycin C. Steroids were discontinued after 5 months. The patient has normal renal function in June, 1964.
FIGURE 2
FIGURE 2
Use of steroid pretreatment in a patient (LD 47) who received a homograft from his brother. Both were A blood type. Three days after operation, acute wound tenderness, hematuria, and anuria developed. Immediate relief followed the first dose (150 r) of transplant irradiation. Restoration of function was so rapid that creatinine clearance, which was based on a 24-hr urine collection, had only slight depression although early azotemia is evident. A second reversible rejection occurred at 14 days with recurrence of renal failure, weight gain, and temporary depression of white count. Note that steroids completely masked the fever of rejection. The patient has normal renal function in June, 1964, more than 150 days after operation (see Table 1).
FIGURE 3
FIGURE 3
Course of a patient (LD 9) who had 3 separate early rejection crises beginning after 5, 34, and 71 days. Note decline of sodium excretion on each occasion and reversal of pattern with increases of prednisone doses. He died 10 days after emergency operative treatment of a bleeding duodenal ulcer. At autopsy, multiple fungal brain abscesses were also found as well as pneumonia. Total survival was 207 days. This patient had a thymectomy 85 days before homotransplantation.
FIGURE 4
FIGURE 4
Two photomicrographs of the renal homotransplant from Patient LD 9 who died at 207 days. Rejection episodes at 5, 34, and 71 days had been successfully reversed. A. There is widespread tubular atrophy and interstitial fibrosis, but very little cellular infiltration. Hematoxylin and eosin stain, × 150. B. The absence of peritubular capillaries should be noted. A dilated atrophic tubule (arrow) is lined by flattened regenerating epithelium. Hematoxylin and eosin stain, × 250.
FIGURE 5
FIGURE 5
Course of a patient (LD 10) who died of late rejection 295 days after homotransplantation. The donor was unrelated. The diagnosis of rejection was first made at 229 days, but effective adjustments in therapy were not made. Note the transient fall in blood urea nitrogen after local irradiation of the transplant. Vigorous therapy was withheld for too long, and uremia became progressive and irreversible. Terminally, he had multiple pulmonary emboli.
FIGURE 6
FIGURE 6
Homograft from Patient LD 10, as seen at autopsy 295 days after operation. Upper photograph: the capsule is partly stripped, showing the smooth subcapsular surface with occasional tiny petechial hemorrhages and persistent fetal lobation. Lower photograph: the cut cortex bulges over the capsule, and a few pinpoint cortical hemorrhages are present. Otherwise, the appearance is normal. Weight was 260 g.
FIGURE 7
FIGURE 7
Two photomicrographs of the renal homotransplant from Patient LD 10 who died at 295 days in a rejection phase. A. There is fibrinoid necrosis (arrow) of part of the wall of an afferent arteriole with extension of the process into the glomerular tuft capillaries. The tubules are atrophic and the interstitium shows fibrosis and some edema. Hematoxylin and eosin stain, × 350. B. An arcuate artery shows marked fibrous intimal thickening. Elastic/van Gieson stain, × 200.
FIGURE 8
FIGURE 8
Severe delayed rejection in a patient (LD 23) who received a homograft from an unrelated donor. Note rises in blood urea nitrogen and declines in creatinine clearance after discontinuance of steroid therapy. Creatinine clearance began to rise after institution of emergency therapy, although the azotemia became temporarily worse. Further improvement in renal function continued after preparation of this graph; during the last 2 weeks of May, 1964, and the first week of June, 1964, creatinine clearances averaged 85 ml/min and blood urea nitrogen averaged 32.
FIGURE 9
FIGURE 9
Delayed rejection in a patient (LD 30) who received a homograft from an unrelated donor. Deterioration of renal function occurred after reduction of prednisone from 45 to 30 mg/day. Note transient improvement after a course of local transplant irradiation. Stable renal function was not obtained until the steroid doses had been returned to the previous higher levels.
FIGURE 10
FIGURE 10
Late rejection (Patient LD 12) appearing 300 days after homotransplantation and 6 months after discontinuance of steroid therapy. The homograft was provided by the patient’s brother.
FIGURE 11
FIGURE 11
Delayed rejection in a 15-year-old boy (LD 13) who received a kidney from his mother. After steroids were stopped, there was a gradual fall of creatinine clearance. The patient had no symptoms. Note gradual restoration of creatinine clearance after the institution of 60 mg/day prednisone.
FIGURE 12
FIGURE 12
Intravenous pyelogram 4 months after homotransplantation in Patient LD 39. A contrast intensification technique was used. Note the partial obstruction at the ureteroneocystostomy. At a subsequent secondary operation, the proximal ureter of the homograft was anastomosed to the patient’s own right ureter, which had not been removed at the time of the original right nephrectomy. The result was satisfactory.
FIGURE 13
FIGURE 13
Course of a 21-year-old woman, LD 27, who received a homograft from an unrelated male donor. Both were of A blood type. Early postoperative rejection was very mild. After 190 days, she suddenly became anuric, subsequently alternating with bouts of brisk diuresis. Although she was treated as an acute rejection, it was subsequently demonstrated that she had severe midureteric stricture that was thought to be a consequence of late healing that followed a previous rejection. After correction of the mechanical difficulty she has been well.
FIGURE 14
FIGURE 14
Intravenous pyelograms of same case (LD 27) shown in Figure 13. Top photograph: intravenous pyelogram showing high-grade obstruction of the homograft midureter. Bottom photograph: appearance after resection of the stenosed ureter and re-anastomosis to the patient’s own ipsilateral ureter. The anastomotic site is shown with an arrow. The somewhat dilated distal portion is the patient’s own ureter, which had previously been demonstrated to have reflux.
FIGURE 15
FIGURE 15
Chronic course of Patient LD 2 who received a homotransplantation from his sister in January, 1963. The patient was of A blood type. His sister was B. Note progressive improvement in creatinine clearance, starting after 3 postoperative months. Prednisone was discontinued after 230 days. The patient had a preliminary thymectomy.
FIGURE 16
FIGURE 16
Appearance of aspetic necrosis of the femoral head in two young women after transplantation. Both were on prednisone therapy at the time of this delayed complication. Upper photograph: Patient LD 22. Lower photograph: Patient LD 50.
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References

    1. Murray JE. Human kidney transplant conference. Transplantation. 1964;2:147. - PubMed
    1. Starzl TE, Marchioro TL, Rifkind D, Holmes JH, Rowlands DT, Waddell WR. Factors in successful renal transplantation. Surgery. 1964;56:296. - PMC - PubMed
    1. Starzl TE. Transplantation of the Kidney. Philadelphia: W. B. Saunders Co.; 1965.
    1. Hume DM, Magee JH, Prout GR, Jr, Kauffman HM, Jr, Cleveland RH, Bower JD, Lee HM, Kramer N. Studies of renal transplantation in men. Ann. NY Acad. Sci. In press. - PubMed
    1. Hamburger J, Crosnier J, Dormont J. Observations in patients with a well tolerated homotransplanted kidney: possibility of a new secondary disease. Ann. NY Acad. Sci. In press. - PubMed

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