- Email: [email protected]
The Role of Blood Transfusions in Renal Transplantation
186
TRANSPLANTATION
D. S. MCCALLY AND C. KANDLER, Division of Urology, Nassau County Medical Center, East Meadow, New York
S. HIRSCH,
N. Y. State J. Med., 83: 316-319 (Mar.) 1983 The authors review the literature and present their experience in the management of 57 patients with bladder trauma (27 contusions and 30 ruptures) seen during a 10-year interval. The bladder may be injured by blunt or penetrating trauma. Of the patients with bladder rupture owing to blunt trauma 66 per cent were associated with fracture of the pelvis. Ten per cent of all cases of fractured pelvis were associated with bladder injury and in 82 per cent of these the rupture was extraperitoneal. The majority of the patients with penetrating trauma had injury to other intra-abdominal organs requiring exploratory laparotomy. Bladder injury was suspected after trauma if the patient had hematuria, dysuria, lower abdominal pain or shock. Evaluation included retrograde urethrography, cystography and excretory urography. The authors emphasize the value of low and high volume cystograms in the diagnosis. Surgical treatment of bladder rupture included closure of the defect in the vesical wall, adequate drainage of the bladder by suprapubic cystotomy and drainage of the perivesical space. Nonoperative treatment consisted of bladder drainage via a large bore (24F minimum) indwelling Foley catheter. All 3 patients who received nonoperative treatment had satisfactory results. However, the authors emphasize the need for proper selection of patients for nonoperative treatment using strict criteria that were discussed in detail. N. S. D. 2 tables, 12 references
The authors used the donor-specific transfusion protocol for all 1-haplotype matches, regardless of the mixed lymphocyte culture results. Donor-specific transfusion results have involved only highly reactive mixed lymphocyte culture donor-recipient pairs, and it can be expected that the low mixed lymphocyte culture group probably will yield at least similar results. Cadaver transplantation is considered for those patients without a potential family donor. The marked improvement in graft survival achieved in the authors' patients with 1 to 5 transfusions, without additional improvement with >5 transfusions, suggests that 3 transfusions are reasonable for pretransplant management until additional data become available. This would minimize the risk of unfavorable sensitization and post-transfusion hepatitis. As in the donor-specific transfusion protocol, several transfusions from a single donor could be just as effective potentially as currently is being evaluated. Blood transfusions before cadaver transplantation are indicated for all candidates to avoid the low graft survival rate observed in recipients who have not received transfusions. Certainly, the beneficial effects of excessive transfusions are outweighed by the increased risks of hepatitis and sensitization. W. W. K. 4 figures, 2 tables, 36 references
Histocompatibility Testing in Clinical Renal Transplantation W. E. BRAUN, Histocompatibility and lmmunogenetics Laboratory, Medical Renal Transplantation Service, Department of Hypertension and Nephrology, Cleveland Clinic Foundation, Cleveland, Ohio
Urol. Clin. N. Amer., 10: 231-242 (May) 1983
TRANSPLANTATION The Role of Blood Transfusions in Renal Transplantation
0.
SALVATIERRA, JR., F. VINCENTI, W. J. C. AMEND, JR., M. R. GAROVOY, D. POTTER AND N. J. FEDUSKA, Transplant
Service, University of California School of Medicine at San Francisco, San Francisco, California Urol. Clin. N. Amer., 10: 243-252 (May) 1983 The ultimate objective of renal transplantation is to obtain maximum graft and patient survival. Of all therapeutic innovations introduced for kidney transplantation blood transfusions probably are the simplest, safest and most cost-effective in improving the outcome for transplant recipients. The most attractive aspect of transfusion therapy is that it improves graft survival without suppressing concomitantly the immune response to infectious organisms. After the initial report in 1973 that blood transfusions were associated with improved graft survival in cadaver transplantation, striking results have been achieved with the donorspecific blood transfusion protocol introduced in 1978. The purpose of the article assesses the role of blood transfusions before cadaver and living related renal transplantation. Pre-transplant blood transfusions have a definite role in improving graft survival of living related and cadaver organs. After the results of transplantation and the influence of pretransplant transfusions were assessed the authors developed a strategy for selection of donors and use of pre-transplant transfusion to obtain the best possible outcome in patients with end stage renal disease electing transplantation.
The human lymphocyte antigen (HLA) system is composed of at least 5 series of antigens controlled by genetic loci on chromosome 6 in man in a region known as the major histocompatibility complex. The series of antigens are named according to the locus controlling that series (A, B, C, D and DR) followed by numeric designations. However, these antigens also have been grouped according to the techniques used to identify them, so that the A, B, C and DR series also are called serologically defined antigens, and those of the D locus are called cellularly defined antigens because they are detected by mixed lymphocyte culture. More recently, the antigens have been classified by immunologists according to their function and biochemistry as class I (A, Band C series) and class II (D and DR series). Although classes I and II antigens can elicit an antibody response, class I antigens act as targets of cytotoxic T cells, and class II antigens have an important function in antigen presentation in vivo and in stimulation of the proliferative response of the mixed lymphocyte culture in vitro. Class I antigens are present on virtually all nucleated cells in the body, including T and B lymphocytes and platelets, whereas class II antigens are expressed only on B lymphocytes, monocytes, macrophages, some types of endothelial cells, Langerhans' cells and activated T lymphocytes or those in certain disease states, such as rheumatoid arthritis. However, class II antigens are not expressed on platelets or unstimulated T cells. In the kidney class I antigens appear to be distributed universally on the glomeruli, vasculature (although less on the capillaries) and tubules. In contrast, class II antigens seem to be absent from Bowman's capsule, large vessels and tubules but occur in high density on interstitial dendritic cells.
TRANSPLANTATION
D. S. MCCALLY AND C. KANDLER, Division of Urology, Nassau County Medical Center, East Meadow, New York
S. HIRSCH,
N. Y. State J. Med., 83: 316-319 (Mar.) 1983 The authors review the literature and present their experience in the management of 57 patients with bladder trauma (27 contusions and 30 ruptures) seen during a 10-year interval. The bladder may be injured by blunt or penetrating trauma. Of the patients with bladder rupture owing to blunt trauma 66 per cent were associated with fracture of the pelvis. Ten per cent of all cases of fractured pelvis were associated with bladder injury and in 82 per cent of these the rupture was extraperitoneal. The majority of the patients with penetrating trauma had injury to other intra-abdominal organs requiring exploratory laparotomy. Bladder injury was suspected after trauma if the patient had hematuria, dysuria, lower abdominal pain or shock. Evaluation included retrograde urethrography, cystography and excretory urography. The authors emphasize the value of low and high volume cystograms in the diagnosis. Surgical treatment of bladder rupture included closure of the defect in the vesical wall, adequate drainage of the bladder by suprapubic cystotomy and drainage of the perivesical space. Nonoperative treatment consisted of bladder drainage via a large bore (24F minimum) indwelling Foley catheter. All 3 patients who received nonoperative treatment had satisfactory results. However, the authors emphasize the need for proper selection of patients for nonoperative treatment using strict criteria that were discussed in detail. N. S. D. 2 tables, 12 references
The authors used the donor-specific transfusion protocol for all 1-haplotype matches, regardless of the mixed lymphocyte culture results. Donor-specific transfusion results have involved only highly reactive mixed lymphocyte culture donor-recipient pairs, and it can be expected that the low mixed lymphocyte culture group probably will yield at least similar results. Cadaver transplantation is considered for those patients without a potential family donor. The marked improvement in graft survival achieved in the authors' patients with 1 to 5 transfusions, without additional improvement with >5 transfusions, suggests that 3 transfusions are reasonable for pretransplant management until additional data become available. This would minimize the risk of unfavorable sensitization and post-transfusion hepatitis. As in the donor-specific transfusion protocol, several transfusions from a single donor could be just as effective potentially as currently is being evaluated. Blood transfusions before cadaver transplantation are indicated for all candidates to avoid the low graft survival rate observed in recipients who have not received transfusions. Certainly, the beneficial effects of excessive transfusions are outweighed by the increased risks of hepatitis and sensitization. W. W. K. 4 figures, 2 tables, 36 references
Histocompatibility Testing in Clinical Renal Transplantation W. E. BRAUN, Histocompatibility and lmmunogenetics Laboratory, Medical Renal Transplantation Service, Department of Hypertension and Nephrology, Cleveland Clinic Foundation, Cleveland, Ohio
Urol. Clin. N. Amer., 10: 231-242 (May) 1983
TRANSPLANTATION The Role of Blood Transfusions in Renal Transplantation
0.
SALVATIERRA, JR., F. VINCENTI, W. J. C. AMEND, JR., M. R. GAROVOY, D. POTTER AND N. J. FEDUSKA, Transplant
Service, University of California School of Medicine at San Francisco, San Francisco, California Urol. Clin. N. Amer., 10: 243-252 (May) 1983 The ultimate objective of renal transplantation is to obtain maximum graft and patient survival. Of all therapeutic innovations introduced for kidney transplantation blood transfusions probably are the simplest, safest and most cost-effective in improving the outcome for transplant recipients. The most attractive aspect of transfusion therapy is that it improves graft survival without suppressing concomitantly the immune response to infectious organisms. After the initial report in 1973 that blood transfusions were associated with improved graft survival in cadaver transplantation, striking results have been achieved with the donorspecific blood transfusion protocol introduced in 1978. The purpose of the article assesses the role of blood transfusions before cadaver and living related renal transplantation. Pre-transplant blood transfusions have a definite role in improving graft survival of living related and cadaver organs. After the results of transplantation and the influence of pretransplant transfusions were assessed the authors developed a strategy for selection of donors and use of pre-transplant transfusion to obtain the best possible outcome in patients with end stage renal disease electing transplantation.
The human lymphocyte antigen (HLA) system is composed of at least 5 series of antigens controlled by genetic loci on chromosome 6 in man in a region known as the major histocompatibility complex. The series of antigens are named according to the locus controlling that series (A, B, C, D and DR) followed by numeric designations. However, these antigens also have been grouped according to the techniques used to identify them, so that the A, B, C and DR series also are called serologically defined antigens, and those of the D locus are called cellularly defined antigens because they are detected by mixed lymphocyte culture. More recently, the antigens have been classified by immunologists according to their function and biochemistry as class I (A, Band C series) and class II (D and DR series). Although classes I and II antigens can elicit an antibody response, class I antigens act as targets of cytotoxic T cells, and class II antigens have an important function in antigen presentation in vivo and in stimulation of the proliferative response of the mixed lymphocyte culture in vitro. Class I antigens are present on virtually all nucleated cells in the body, including T and B lymphocytes and platelets, whereas class II antigens are expressed only on B lymphocytes, monocytes, macrophages, some types of endothelial cells, Langerhans' cells and activated T lymphocytes or those in certain disease states, such as rheumatoid arthritis. However, class II antigens are not expressed on platelets or unstimulated T cells. In the kidney class I antigens appear to be distributed universally on the glomeruli, vasculature (although less on the capillaries) and tubules. In contrast, class II antigens seem to be absent from Bowman's capsule, large vessels and tubules but occur in high density on interstitial dendritic cells.