- Email: [email protected]
MACHINE-PERFUSED CADAVER KIDNEYS
614
symptomless, undetected, and yet
amenable to correction, correction be made except by screening ? In this sense, screening is admittedly one of several semantic alternates for a variety of procedures like " periodic health check " or pre-school assessment " which, at any stage of life, can be beneficially organised by general practitioners, health centres, health boards, companies, and other organisations with medical collaboration. Are Sackett and Holland doubting the benefit of such procedures in the early detection of certain cancers (environmental and occupational), pneumoconiosis, dental caries, anatomical disorders (congenital dislocation of hip), genetic disorders constitutional disorders (hypertension), nutritional disorders (rickets), and infections (congenital syphilis), to mention only a few examples ? If, as we believe, academic epidemiology has a growing application to practical medicine and health education, it must use its resource to identify preventable disorders and to evaluate methods of intervention. This is its privileged and unique role among medical disciplines. To disavow this role and opportunity is a disservice to colleagues in other branches of medicine and a discouragement to those others of us in community medicine who see in the implementation of primary and secondary preventive procedures a prospect for a more efficient, more humane, and more economical health service.
how
CLINICAL RESULTS OF 66 KIDNEYS SELECTED FOR PERFUSION
(60
TRANSPLANTED)
can
"
(phenylketonuria),
University Department of Community Medicine, Ruchill Hospital, G20 9NB.
Glasgow
A. P. CURRAN C. R. GILLIS V. M. HAWTHORNE G. T. STEWART.
MACHINE-PERFUSED CADAVER KIDNEYS SIR,-We suggest that the improved results of machineperfused cadaver kidneys reported by Mr Sheil and his colleagues (Aug. 16, p. 287) compared with those in the U.K. are due to differing criteria for selection of kidneys for perfusion. It has been the practice at this centre to select for perfusion kidneys which have a poor agonal history or dubious washout characteristics, to allow viability studies to be performed. In addition, perfusion preservation is used where it is anticipated that the period of preservation may be
prolonged.
presented we would have discarded none of the kidneys perfused by the Sydney group. While Mr Sheil and his colleagues undertake the management of donors, enabling almost all to be ventilated terminally, only 78% of kidneys perfused at this centre were retrieved from donors receiving ventilatory support. In addition, 27% had been exposed to periods of anoxia and hypotension. Since most kidneys are retrieved by teams outside this centre, the average time between retrieval and the start of perfusion is 6 hours compared with 2 hours 25 minutes in Sydney. All these differences suggest that many kidneys perfused here have received a more severe injury than those in the Sydney trial. Whilst service needs militate against properly controlled trials, publications from this centre and elsewhere demonstrate the need for the clear definition of criteria used in selection and treatment together with standardisation of follow-up parameters to allow some validity in comparisons between centres.
Royal Victoria Infirmary, Newcastle upon Tyne WE1 4LP.
C. K. R. R.
P. ST. J. NEWMAN BAXBY HALL M. R. TAYLOR.
SALIVARY ANTIBODY RESPONSE TO ORAL VACCINE is clinical evidence 1,2 that a comsome SIR,-There mercial oral vaccine containing extracts of pneumococci, haemolytic streptococci (groups A, C, and G), Neisseria
catarrhalis, Hamophilus influenzce (type B), Klebsiella pneumonia, and Staphylococcus aureus may afford a degree of protection against bacterial infections of the upper respiratory tract associated with the common cold. In view of the suggestion 3,4 that secretory immunoglobulins may play an important role in oral immunity, it was thought
The Gambro perfusion machine PF2D and PF2A is used for preservation and viability testing.1 The kidney is perfused with r.r.F.22 and pressure and flow are measured; pressure is slowly increased to a maximum of 55 mm Hg. Perfusate concentrations of hydrogen ions and lactate are estimated at intervals during the first hour in addition to continued observation of pressure and flow. A review of the first two years of this practice suggests that, despite selecting for perfusion kidneys which might be expected to have a poor prognosis, our overall results compare favourably with the results elsewhere in the U.K.3 Since the majority of kidneys transplanted outside this centre do not undergo perfusion, our results support the observation that perfusion does not have a detrimental effect. However, analysis of our figures with regard to duration of perfusion shows poorer results where the period exceeds nine hours (see accompanying table). Of 66 kidneys perfused 6 were discarded following poor perfusion parameters. Each was associated with marked lactic acidosis and never reached a flow of 0-5 ml perfusate per g of kidney per minute despite exceeding the upper On the data limits of permitted perfusion pressure.
worth while to look for salivary antibody in persons taking an oral vaccine. A preliminary trial revealed no demonstrable changes in the throat bacterial flora or in serum-antibody titres in
Baxby, K., Taylor, R. M. R., Anderson, M., Johnson, R. W. G., Swinney, J. Lancet, 1974, ii, 977. 2. Johnson, R. W. G., Anderson, M., Flear, C. T. G., Murray, S. G. H., Taylor, R. M. R., Swinney, J. Transplantation, 1972, 13, 270. 3. National Organ Matching Service Report, 1973.
Newbold, G. F., Savage, R. M. Community Med. 1971, 126, 37. Price, H. C., Henly, G. Practitioner, 1974, 213, 720. Adinolfi, M., Glyn, A. A., Lindsay, M., Milne, C. M. J. Immun. 1966, 10, 517. 4. Lehner, T., Cardwell, J. E., Clarry, E. D. Lancet, 1967, i, 1294.
1.
TABLE I-RECIPROCAL SALIVARY HaeMAGGLUTINATION TITRES FOR STAPHYLOCOCCUS AUREUS
————————————————————————————————————:———————i——————
1. 2. 3.
symptomless, undetected, and yet
amenable to correction, correction be made except by screening ? In this sense, screening is admittedly one of several semantic alternates for a variety of procedures like " periodic health check " or pre-school assessment " which, at any stage of life, can be beneficially organised by general practitioners, health centres, health boards, companies, and other organisations with medical collaboration. Are Sackett and Holland doubting the benefit of such procedures in the early detection of certain cancers (environmental and occupational), pneumoconiosis, dental caries, anatomical disorders (congenital dislocation of hip), genetic disorders constitutional disorders (hypertension), nutritional disorders (rickets), and infections (congenital syphilis), to mention only a few examples ? If, as we believe, academic epidemiology has a growing application to practical medicine and health education, it must use its resource to identify preventable disorders and to evaluate methods of intervention. This is its privileged and unique role among medical disciplines. To disavow this role and opportunity is a disservice to colleagues in other branches of medicine and a discouragement to those others of us in community medicine who see in the implementation of primary and secondary preventive procedures a prospect for a more efficient, more humane, and more economical health service.
how
CLINICAL RESULTS OF 66 KIDNEYS SELECTED FOR PERFUSION
(60
TRANSPLANTED)
can
"
(phenylketonuria),
University Department of Community Medicine, Ruchill Hospital, G20 9NB.
Glasgow
A. P. CURRAN C. R. GILLIS V. M. HAWTHORNE G. T. STEWART.
MACHINE-PERFUSED CADAVER KIDNEYS SIR,-We suggest that the improved results of machineperfused cadaver kidneys reported by Mr Sheil and his colleagues (Aug. 16, p. 287) compared with those in the U.K. are due to differing criteria for selection of kidneys for perfusion. It has been the practice at this centre to select for perfusion kidneys which have a poor agonal history or dubious washout characteristics, to allow viability studies to be performed. In addition, perfusion preservation is used where it is anticipated that the period of preservation may be
prolonged.
presented we would have discarded none of the kidneys perfused by the Sydney group. While Mr Sheil and his colleagues undertake the management of donors, enabling almost all to be ventilated terminally, only 78% of kidneys perfused at this centre were retrieved from donors receiving ventilatory support. In addition, 27% had been exposed to periods of anoxia and hypotension. Since most kidneys are retrieved by teams outside this centre, the average time between retrieval and the start of perfusion is 6 hours compared with 2 hours 25 minutes in Sydney. All these differences suggest that many kidneys perfused here have received a more severe injury than those in the Sydney trial. Whilst service needs militate against properly controlled trials, publications from this centre and elsewhere demonstrate the need for the clear definition of criteria used in selection and treatment together with standardisation of follow-up parameters to allow some validity in comparisons between centres.
Royal Victoria Infirmary, Newcastle upon Tyne WE1 4LP.
C. K. R. R.
P. ST. J. NEWMAN BAXBY HALL M. R. TAYLOR.
SALIVARY ANTIBODY RESPONSE TO ORAL VACCINE is clinical evidence 1,2 that a comsome SIR,-There mercial oral vaccine containing extracts of pneumococci, haemolytic streptococci (groups A, C, and G), Neisseria
catarrhalis, Hamophilus influenzce (type B), Klebsiella pneumonia, and Staphylococcus aureus may afford a degree of protection against bacterial infections of the upper respiratory tract associated with the common cold. In view of the suggestion 3,4 that secretory immunoglobulins may play an important role in oral immunity, it was thought
The Gambro perfusion machine PF2D and PF2A is used for preservation and viability testing.1 The kidney is perfused with r.r.F.22 and pressure and flow are measured; pressure is slowly increased to a maximum of 55 mm Hg. Perfusate concentrations of hydrogen ions and lactate are estimated at intervals during the first hour in addition to continued observation of pressure and flow. A review of the first two years of this practice suggests that, despite selecting for perfusion kidneys which might be expected to have a poor prognosis, our overall results compare favourably with the results elsewhere in the U.K.3 Since the majority of kidneys transplanted outside this centre do not undergo perfusion, our results support the observation that perfusion does not have a detrimental effect. However, analysis of our figures with regard to duration of perfusion shows poorer results where the period exceeds nine hours (see accompanying table). Of 66 kidneys perfused 6 were discarded following poor perfusion parameters. Each was associated with marked lactic acidosis and never reached a flow of 0-5 ml perfusate per g of kidney per minute despite exceeding the upper On the data limits of permitted perfusion pressure.
worth while to look for salivary antibody in persons taking an oral vaccine. A preliminary trial revealed no demonstrable changes in the throat bacterial flora or in serum-antibody titres in
Baxby, K., Taylor, R. M. R., Anderson, M., Johnson, R. W. G., Swinney, J. Lancet, 1974, ii, 977. 2. Johnson, R. W. G., Anderson, M., Flear, C. T. G., Murray, S. G. H., Taylor, R. M. R., Swinney, J. Transplantation, 1972, 13, 270. 3. National Organ Matching Service Report, 1973.
Newbold, G. F., Savage, R. M. Community Med. 1971, 126, 37. Price, H. C., Henly, G. Practitioner, 1974, 213, 720. Adinolfi, M., Glyn, A. A., Lindsay, M., Milne, C. M. J. Immun. 1966, 10, 517. 4. Lehner, T., Cardwell, J. E., Clarry, E. D. Lancet, 1967, i, 1294.
1.
TABLE I-RECIPROCAL SALIVARY HaeMAGGLUTINATION TITRES FOR STAPHYLOCOCCUS AUREUS
————————————————————————————————————:———————i——————
1. 2. 3.