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Bilateral, en bloc, kidney homotransplantation in the dog
PRACTICAL
SURGICAL
SUGGESTION
Bilateral, en Bloc, Kidney H o m o t r ans p l a n ta ti o n in the D o g HARRY ~']:. NELSON, JR., M.D., IRWIN B. BORUCtIOW, M.D., AND BENJAMIN F. MILLER, M.D.,
Philadelphia, Pennsylvania
From the tlarrison Department of Surgical Research, School of xl[edicine, University of Pennsylvanht, Philadelphia, Pennsylvania.
T tItIS he
INVESTIGATION 'was
designed to study
effect of bilateral t r a n s p l a n t a t i o n in prolonging s u r v i v a l of dogs u n t r e a t e d b y a n y of t h e i m m u n o s u p p r e s s i v e technics: I t was h o p e d t h a t t h e larger q u a n t i t y of a n t i g e n s u p p l i e d b y t w o h o m o g r a f t k i d n e y s would b y m e a n s of , ' i m m u n o p a r a l y s i s " d e l a y or m o d i f y t h e r e j e c t i o n response. T h e " e n b l o c " t e c h n i c described b y Alexis C a r r e l was e m p l o y e d for this purpose [1]. METHOD
The experiment was performed five times utilizing mongrel dogs weighing 15 kg, as donors and recipients. The animals were anesthetized with intravenous Nembutal '-.~. Using an aseptic technic both kidneys and ureters of the donor animal were removed en bloc with the adjacent segment of aorta and vena cava. T h e recipient animal was nephrectomized bilaterally, and the aorta and vena cava were divided at the level of the inferior ruesenteric artery. End to end anastom6sis of the vena cava and aorta to the interposed seganent of donor vena eava and aorta was carried out. The ureters were implanted into the bladder. The total period of ischemia in each case was about one hour and fifty minutes. All of the dogs except the first (No. 1413) had been given active immunization against canine distemper and hepatitis three weeks preoperatively. No specific immunosuppressive technics were used. All animals received penicillin and streptomycin postoperatively and all were fed the usual kennel
830
rations except when intravenous fluids becmne necessary shortly before death. Determinations of blood urea nitrogen and creatinine, hemoglobin, white blood cell count, rectal temperature, weight, and urine proteins were performed at regular intervals. Needle biopsies of the transplanted kidneys were obtained once or twice a week.. Complete postmortem examinations were performed on all dogs. RESULTS
F o u r dogs lived b e t w e e n eleven a n d sixteen days. T h e a n i m a l s b e c a m e oliguric (less t h a n 100 co. of u r i n e per d a y ) on t h e n i n t h to t w e l f t h d a y . Serial r e n a l biopsies a n d b o t h gross a n d microscopic a u t o p s y specimens s h o w e d t y p i c a l h o m o g r a f t rejection. T h e r e m a i n i n g dog in this series (No. 1413) s u r v i v e d t w e n t y - f i v e days. T h i s a n i m a l h a d been selected for d e v e l o p m e n t of the technic a n d h a d received no a c t i v e i m m u n i z a t i o n . One week a f t e r t r a n s p l a n t a t i o n t h e a n i m a l was clinically well a n d t h e blood u r e a n i t r o g e n hacl fallen to a n o r m a l level. D u r i n g t h e second p o s t o p e r a t i v e week a n u p p e r r e s p i r a t o r y illness a n d a clinical p i c t u r e c o m p a t i b l e with d i s t e m p e r developed. T h r e e d a y s prior to d e a t h blood c u l t u r e s were positive for Clostridi u m t e ~ t i u m a n d s i m u l t a n e o u s u r i n a r y cultures for E s c h e r i e h i a coli. An e n d o g e n o u s c r e a t i n i n e clearance p e r f o r m e d on t h e t w e n t i e t h p o s t o p e r a t i v e d a y was 26.6 c c . / m i n u t e w i t h a t w e n t y - f o u r h o u r urine p r o t e i n excretion of 1.7 gin. Histologic s t u d y of t w o needle biopsies t a k e n on t h e f o u r t e e n t h a n d t w e n t i e t h d a y s American Journal of Surgery
Kidney
Homotransplantation
p o s t o p e r a t i v e l y g a v e m i n i m a l e v i d e n c e of homograft rejection, Postmortem examination s h o w e d viable k i d n e y s bilaterally, no u r e t e r a l o b s t r u c t i o n , a n d a histologic p i c t u r e of a c u t e p y e l o n e p h r i t i s w i t h m i n i m a l e v i d e n c e of t r a n s p l a n t rejecti~m. N o e v i d e n c e of c a n i n e dist e m p e r w a s s~en on m i c r o s c o p i c e x a m i n a t i o n of t h e a u t o p s y material. COMMENTS E x p e r i m e n t s in m a n y l a b o r a t o r i e s as well as o u r o w n h a v e s h o w n t h a t a n u n t r e a t e d d o g has c e s s a t i o n of renal f u n c t i o n in a u n i l a t e r a l k i d n e y h o m o g r a f t b e t w e e n five a n d t w d v e d a y s [2]. T h e c o u r s e of f o u r u n t r e a t e d dogs w i t h b i l a t e r a l en bloc renal h o m o t r a n s p l a n t s w a s sinfilar to t h a t in u n i l a t e r a l t r a n s p l a n t s . T h e first d o g in this series s h o w e d a p r o l o n g e d s u r v i v a l of t w e n t y - f i v e d a y s w i t h a d e q u a t e urinary output until two days before death w h e n t h e a n i m a l was in s h o c k f r o m o v e r whelnfing sepsis. T h e e a r l y clinical p i c t u r e w a s compatible with distemper although the typical inclusion b o d i e s w e r e n o t f o u n d o n h i s t o l o ~ c e x a m i n a t i o n . T h e r e w a s m i n i m a l histologic e v i d e n c e of homog-raft rejection. G e n e t i c c o m p a t i b i l i t y b e t w e e n this d o g a n d its d o n o r s e e m e d unlikely, b u t it is p o s s i b l e t h a t a v i r a l illness w h i c h b e c a m e m a n i f e s t d u r i n g t h e postoperative period altered the i m m u n e r e s p o n s e in this a n i m a l [3]. T h e o t h e r f o u r a n i m a l s - r e j e c t e d t h e hom o l o g o u s t r a n s p l a n t in such a classical fashion t h a t it s e e m s r e a s o n a b l e t o a s s u m e t h a t it is n o t possible to p r o d u c e i m m u n o p a r a l y s i s in
Vol. 109, June 1965
831
dogs b y m e r e l y d o u b l i n g t h e a m o u n t of h o m o g r a f t tissue. I t m a y b e s p e c u l a t e d t h a t t h e r e is, n e v e r t h e l e s s , t h e p o s s i b i l i t y t h a t two kidneys plus immunosuppressive therapy m a y p r o v i d e b e t t e r s u r v i v a l t h a n a single k i d n e y w i t h t h e santo t h e r a p y . T h e t e c h n i c of e n bloc t r a n s p l a n t a t i o n m a y b e useful in e x p e r i m e n t s in w h i c h o n e k i d n e y of t h e p a i r c o u l d a c t as the " g e n e t i c " c o n t r o l for a p r o c e d u r e which has b e e n a p p l i e d to t h e other kidney. SUMMARY
D o u b l i n g the a m o u n t of r e n a l h o m o g r a f t tissue b y t h e en bloc t e c h n i c did n o t p r o d u c e e v i d e n c e of i m m u n o p a r a l y s i s in f o u r of five dogs. In t h e one i n s t a n c e of definite p r o l o n g a tion of renal f u n c t i o n , it is s u g g e s t e d t h a t a c o n c o m i t a n t viral illness w a s t h e i m p o r t a n t factor. A c k n o w l e d g m e n t : T h e a u t h o r s express their gTatitude to G e o r g e E v a n s , M.D., D e p a r t m e n t of Surgical P a t h o l o g y , a n d also to L o u i s e Kline, R.N.
REFERENCES 1. CARREL, A. Transplantation in mass of the kidneys, J. Exper. M~ed., 10" 98, 1908. 2. CALN~, R. Y:, ALEXANDRE, G. P. J., and Mu~,~AV, J. E. A study of the effects of drugs in prolonging survival of homologous renal transplants in dogs. Ann. New York Acad. Sc., 99: 743, 1962. 3. I~{~LL,~AN,~V. J. and \VETTON, 1~. Depression of the tuberculin reaction by attenuated measles virus vaccine. J. Lab. & Clin. P~[ed.,61 : 453, 1963.
SURGICAL
SUGGESTION
Bilateral, en Bloc, Kidney H o m o t r ans p l a n ta ti o n in the D o g HARRY ~']:. NELSON, JR., M.D., IRWIN B. BORUCtIOW, M.D., AND BENJAMIN F. MILLER, M.D.,
Philadelphia, Pennsylvania
From the tlarrison Department of Surgical Research, School of xl[edicine, University of Pennsylvanht, Philadelphia, Pennsylvania.
T tItIS he
INVESTIGATION 'was
designed to study
effect of bilateral t r a n s p l a n t a t i o n in prolonging s u r v i v a l of dogs u n t r e a t e d b y a n y of t h e i m m u n o s u p p r e s s i v e technics: I t was h o p e d t h a t t h e larger q u a n t i t y of a n t i g e n s u p p l i e d b y t w o h o m o g r a f t k i d n e y s would b y m e a n s of , ' i m m u n o p a r a l y s i s " d e l a y or m o d i f y t h e r e j e c t i o n response. T h e " e n b l o c " t e c h n i c described b y Alexis C a r r e l was e m p l o y e d for this purpose [1]. METHOD
The experiment was performed five times utilizing mongrel dogs weighing 15 kg, as donors and recipients. The animals were anesthetized with intravenous Nembutal '-.~. Using an aseptic technic both kidneys and ureters of the donor animal were removed en bloc with the adjacent segment of aorta and vena cava. T h e recipient animal was nephrectomized bilaterally, and the aorta and vena cava were divided at the level of the inferior ruesenteric artery. End to end anastom6sis of the vena cava and aorta to the interposed seganent of donor vena eava and aorta was carried out. The ureters were implanted into the bladder. The total period of ischemia in each case was about one hour and fifty minutes. All of the dogs except the first (No. 1413) had been given active immunization against canine distemper and hepatitis three weeks preoperatively. No specific immunosuppressive technics were used. All animals received penicillin and streptomycin postoperatively and all were fed the usual kennel
830
rations except when intravenous fluids becmne necessary shortly before death. Determinations of blood urea nitrogen and creatinine, hemoglobin, white blood cell count, rectal temperature, weight, and urine proteins were performed at regular intervals. Needle biopsies of the transplanted kidneys were obtained once or twice a week.. Complete postmortem examinations were performed on all dogs. RESULTS
F o u r dogs lived b e t w e e n eleven a n d sixteen days. T h e a n i m a l s b e c a m e oliguric (less t h a n 100 co. of u r i n e per d a y ) on t h e n i n t h to t w e l f t h d a y . Serial r e n a l biopsies a n d b o t h gross a n d microscopic a u t o p s y specimens s h o w e d t y p i c a l h o m o g r a f t rejection. T h e r e m a i n i n g dog in this series (No. 1413) s u r v i v e d t w e n t y - f i v e days. T h i s a n i m a l h a d been selected for d e v e l o p m e n t of the technic a n d h a d received no a c t i v e i m m u n i z a t i o n . One week a f t e r t r a n s p l a n t a t i o n t h e a n i m a l was clinically well a n d t h e blood u r e a n i t r o g e n hacl fallen to a n o r m a l level. D u r i n g t h e second p o s t o p e r a t i v e week a n u p p e r r e s p i r a t o r y illness a n d a clinical p i c t u r e c o m p a t i b l e with d i s t e m p e r developed. T h r e e d a y s prior to d e a t h blood c u l t u r e s were positive for Clostridi u m t e ~ t i u m a n d s i m u l t a n e o u s u r i n a r y cultures for E s c h e r i e h i a coli. An e n d o g e n o u s c r e a t i n i n e clearance p e r f o r m e d on t h e t w e n t i e t h p o s t o p e r a t i v e d a y was 26.6 c c . / m i n u t e w i t h a t w e n t y - f o u r h o u r urine p r o t e i n excretion of 1.7 gin. Histologic s t u d y of t w o needle biopsies t a k e n on t h e f o u r t e e n t h a n d t w e n t i e t h d a y s American Journal of Surgery
Kidney
Homotransplantation
p o s t o p e r a t i v e l y g a v e m i n i m a l e v i d e n c e of homograft rejection, Postmortem examination s h o w e d viable k i d n e y s bilaterally, no u r e t e r a l o b s t r u c t i o n , a n d a histologic p i c t u r e of a c u t e p y e l o n e p h r i t i s w i t h m i n i m a l e v i d e n c e of t r a n s p l a n t rejecti~m. N o e v i d e n c e of c a n i n e dist e m p e r w a s s~en on m i c r o s c o p i c e x a m i n a t i o n of t h e a u t o p s y material. COMMENTS E x p e r i m e n t s in m a n y l a b o r a t o r i e s as well as o u r o w n h a v e s h o w n t h a t a n u n t r e a t e d d o g has c e s s a t i o n of renal f u n c t i o n in a u n i l a t e r a l k i d n e y h o m o g r a f t b e t w e e n five a n d t w d v e d a y s [2]. T h e c o u r s e of f o u r u n t r e a t e d dogs w i t h b i l a t e r a l en bloc renal h o m o t r a n s p l a n t s w a s sinfilar to t h a t in u n i l a t e r a l t r a n s p l a n t s . T h e first d o g in this series s h o w e d a p r o l o n g e d s u r v i v a l of t w e n t y - f i v e d a y s w i t h a d e q u a t e urinary output until two days before death w h e n t h e a n i m a l was in s h o c k f r o m o v e r whelnfing sepsis. T h e e a r l y clinical p i c t u r e w a s compatible with distemper although the typical inclusion b o d i e s w e r e n o t f o u n d o n h i s t o l o ~ c e x a m i n a t i o n . T h e r e w a s m i n i m a l histologic e v i d e n c e of homog-raft rejection. G e n e t i c c o m p a t i b i l i t y b e t w e e n this d o g a n d its d o n o r s e e m e d unlikely, b u t it is p o s s i b l e t h a t a v i r a l illness w h i c h b e c a m e m a n i f e s t d u r i n g t h e postoperative period altered the i m m u n e r e s p o n s e in this a n i m a l [3]. T h e o t h e r f o u r a n i m a l s - r e j e c t e d t h e hom o l o g o u s t r a n s p l a n t in such a classical fashion t h a t it s e e m s r e a s o n a b l e t o a s s u m e t h a t it is n o t possible to p r o d u c e i m m u n o p a r a l y s i s in
Vol. 109, June 1965
831
dogs b y m e r e l y d o u b l i n g t h e a m o u n t of h o m o g r a f t tissue. I t m a y b e s p e c u l a t e d t h a t t h e r e is, n e v e r t h e l e s s , t h e p o s s i b i l i t y t h a t two kidneys plus immunosuppressive therapy m a y p r o v i d e b e t t e r s u r v i v a l t h a n a single k i d n e y w i t h t h e santo t h e r a p y . T h e t e c h n i c of e n bloc t r a n s p l a n t a t i o n m a y b e useful in e x p e r i m e n t s in w h i c h o n e k i d n e y of t h e p a i r c o u l d a c t as the " g e n e t i c " c o n t r o l for a p r o c e d u r e which has b e e n a p p l i e d to t h e other kidney. SUMMARY
D o u b l i n g the a m o u n t of r e n a l h o m o g r a f t tissue b y t h e en bloc t e c h n i c did n o t p r o d u c e e v i d e n c e of i m m u n o p a r a l y s i s in f o u r of five dogs. In t h e one i n s t a n c e of definite p r o l o n g a tion of renal f u n c t i o n , it is s u g g e s t e d t h a t a c o n c o m i t a n t viral illness w a s t h e i m p o r t a n t factor. A c k n o w l e d g m e n t : T h e a u t h o r s express their gTatitude to G e o r g e E v a n s , M.D., D e p a r t m e n t of Surgical P a t h o l o g y , a n d also to L o u i s e Kline, R.N.
REFERENCES 1. CARREL, A. Transplantation in mass of the kidneys, J. Exper. M~ed., 10" 98, 1908. 2. CALN~, R. Y:, ALEXANDRE, G. P. J., and Mu~,~AV, J. E. A study of the effects of drugs in prolonging survival of homologous renal transplants in dogs. Ann. New York Acad. Sc., 99: 743, 1962. 3. I~{~LL,~AN,~V. J. and \VETTON, 1~. Depression of the tuberculin reaction by attenuated measles virus vaccine. J. Lab. & Clin. P~[ed.,61 : 453, 1963.