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R J Tesi

Publications and source records attributed to R J Tesi.

At least 37 records · Page 2Linked to original sources
PubMed1994

The frequency of rejection episodes after combined kidney-pancreas transplant--the impact on graft survival.

The recipients of combined kidney-pancreas transplants (SPK) are unique because they routinely receive two allografts from the same donor. In a previous study, we found that the long-term graft survival of the two allografts was different, with better graft survival seen in the pancreas allograft. In an attempt to understand the reason for the different graft survival in the recipients of organs from the same donor, we have reviewed the incidence and timing of rejection episodes in 160 consecutive technically successful whole-organ bladder-drained SPK performed at a single institution using a uniform immunosuppressive regimen. Rejection episodes were common. A total of 53% of the recipients had at least one episode of rejection in one of the organs. Multiple rejection episodes requiring hospitalization occurred in 23% of the recipients. The kidney allograft had more frequent rejection episodes than the pancreas allograft: 78 patients had 130 renal rejection episodes while only 50 patients had 65 episodes of pancreas rejection. No rejection episodes occurred in 111 pancreas and 82 kidney grafts (P = 0.0014). Multiple rejection episodes were three times as common in the kidney grafts (20%) than in the pancreas grafts (6%; P = 0.0001). The timing of the first rejection episode was also different. The median time to the first kidney rejection episode was 29 days compared with 39 days to the first pancreas rejection episode (P = 0.0191). Graft survival in the organs was equal when stratified by the number of rejection episodes (none, one, > one) per organ (P = 0.9378). These data suggest that the worse long-term kidney graft survival seen in SPK recipients is due to the greater risk of rejection (relative risk: 2.04; [95% conf. interval: 1.29-3.23]) and a greater frequency of rejection episodes of rejection episodes in the kidney (0.81/patient) compared with the pancreas (0.41/patient). The implications for patient management and the possible reasons for the different rates of rejection are discussed.

Adult↗
PubMed1994

Detection of cytomegalovirus in liver transplant biopsies. A comparison of light microscopy, immunohistochemistry, duplex PCR and nested PCR.

The polymerase chain reaction was used to detect cytomegalovirus (CMV) in 91 formalin-fixed paraffin-embedded needle biopsies from 38 liver transplant patients with allograft dysfunction. Thirty donor liver biopsies served as negative controls. PCR results were compared with light microscopy (LM), immunohistochemical staining (IH) for CMV early and late antigen, and clinical data. Primers to the major immediate early gene (MIE) and the viral DNA polymerase gene were duplex amplified. PCR product was reamplified with a nested primer set for the MIE and confirmed by electrophoretic mobilities and dot blotting. Primers for human beta-hemoglobin were used as internal controls. Seventeen of 38 patients had clinical evidence of cytomegalovirus disease, 12 of these were IH-positive, 14 were LM-positive, 15 were duplex PCR-positive and 17 were nested PCR-positive. In addition, duplex PCR was positive in one patient without other evidence of CMV disease, while nested PCR was positive in 12 such patients. The sensitivity and negative predictive value of nested PCR was 100%--however, the specificities and positive predictive values were only 42.9 and 58.6%, respectively. The control group was completely negative by LM, IH, and duplex PCR, however, 6 of 30 patients were nested PCR-positive. The number of nested-positive, duplex-negative patients without CMV disease was significantly greater in the transplant group versus the control group (12/21 vs. 6/30, P < 0.009). The incidence of IgG seropositivity was also significantly greater in the transplant group versus the controls (29/32 vs. 15/24, P < 0.02). We conclude that nested PCR may be an overly sensitive technique for the detection of clinically relevant CMV disease. A negative nested PCR assay for CMV may, however, help rule-out symptomatic CMV infection in an individual case. Duplex PCR showed little advantage over LM, while IH was confirmatory but did not add any new information in this study.

Antigens, Viral↗
PubMed1994

Transmission of hepatitis C by kidney transplantation--the risks.

The use of cadaveric organ donors with positive serologic tests for hepatitis C (HCV) has caused considerable debate. We have reviewed the clinical course of 43 EIA1 HCV-negative recipients who received kidney transplants from EIA1 HCV-positive donors (Study). We have attempted to define the rate of HCV-RNA transmission and to determine the frequency of HCV disease transmission as determined by abnormalities in liver function tests. Viral transmission was assessed using serologic assays for HCV antibody formation (EIA1, EIA2, and Matrix--an automated multiple antigen immunoblot assay) and with PCR testing for the presence of HCV-RNA on recipient sera. Liver function was followed longitudinally in the Study patients and compared with a group of 103 kidney recipients of organs from EIA1 HCV-negative donors (Control). Of the Study patients, 56% became PCR-positive for HCV-RNA, suggesting the transmission of HCV-RNA from the HCV-positive donor. Interpretation of serologic tests for HCV was complex. Currently available first (EIA1) and second (EIA2) generation serologic assays were always negative. The multiple antigen immunoblots assay (Matrix) had a high positive predictive value (93%) for the presence of HCV-RNA transmission, but one-third of Matrix-negative Study patients were PCR-positive (sensitivity = 66%). Currently, only 38% of recipients have HCV-RNA, suggesting that the virus may have been cleared by one-third of Study recipients who had circulating virus. Traditional tests of liver function (ALT, AST, AP, and GGT) were of limited use in predicting HCV-RNA transmission. Average AST, AP, and GGT were similar in the two groups. Average ALT was increased (93 I/U and 47 I/U) in Study and Control patients, respectively, but this difference was not significant. Episodes of abnormal liver function (ALT 60-99 IU for > or = 14 days) occurred in 22% of Study and 10% of Control patients (P = NS) and lasted longer in Study compared with Control patients (301 vs. 138 days; P < 0.02). Hepatitis (ALT > or = 100 IU for > 14 days) occurred with an equal frequency (6.5%) in both groups. The presence of HCV-RNA did not predict episodes of abnormal liver function. Fulminant hepatitis or rapidly progressive cirrhosis did not occur in the recipients of organs from HCV-positive donors. These data demonstrate a high efficiency of transfer of HCV-RNA by kidney transplantation from an HCV-positive donor to an HCV-negative recipient. A majority of the patients have asymptomatic HCV infection.(ABSTRACT TRUNCATED AT 400 WORDS)

Cadaver↗
PubMed1994

Renal transplantation in older people.

Renal transplantation in people 60 years old or more is controversial due to the morbidity associated with immunosuppression and the scarcity of renal allografts. We have reviewed the outcome of 1222 consecutive renal transplants done at a single institution with a uniform immunosuppressive protocol over 10 years. 5-year graft survival was the same in the under sixties as in the sixties and over. Patient survival was worse in the older group (p = 0.0001), but there were significantly fewer immunological graft losses: 11% vs 31% (p = 0.0009; relative risk [RR] = 0.36 [95% confidence interval 0.19-0.66]). A majority of the deaths in both groups were secondary to cardiovascular disease, not due to complications of immunosuppression. We conclude that renal transplantation in people 60 and over has results equivalent to a younger population. Age 60 and over should not be a major factor in considering if a patient is eligible for renal transplantation.

Adult↗
PubMed1994

Xanthogranulomatous pyelonephritis in renal allografts: report of 2 cases.

We report 2 cases of xanthogranulomatous pyelonephritis that occurred in renal transplant recipients. Both cases were successfully treated with antibiotics. The traditional treatment of choice has been nephrectomy. No graft was lost as a result of xanthogranulomatous pyelonephritis and no nephrectomy was required in either patient. The course of these 2 patients is discussed and literature on this disease is reviewed.

Female↗
PubMed1994

Alkaline phosphatase isoforms in serum after liver allograft surgery.

Orthotopic liver transplantation (OLT) is now the only available treatment for end-stage liver disease; the major postoperative complications of OLT are rejection and infection. Fractionation of alkaline phosphatase (ALP) isoforms in serum by isoelectric focusing can be used to identify patients with complications. Reference ranges for liver-function tests (LFT) and liver ALP isoforms were established for post-OLT patients with stable postoperative courses and compared with those of patients with complications. We found canalicular, hepatocyte, and high-molecular-mass ALP to be statistically higher in nearly all patients with complications as compared with patients who had a stable postoperative course; these tests may identify patients requiring a liver biopsy. When used in conjunction with LFT and other clinical findings, ALP isoforms could aid in the monitoring of complications and treatment and in the adjustment of immunosuppressive therapy in stable OLT cases.

Adolescent↗
PubMed1994

Pulsatile kidney perfusion for evaluation of high-risk kidney donors safely expands the donor pool.

Pulsatile preservation of cadaveric kidney allografts allows effective organ preservation and the opportunity to obtain information about the quality of the organ during storage. The use of information obtained by measuring FLOW (ml/min) and renal resistance (mean perfusion pressure/FLOW (ml/min)) while kidneys are undergoing pulsatile perfusion offers quantitative data to determine suitability of an organ for transplant. This may be more accurate than the combination of demographic variables with past and current medical information that has been traditionally used to evaluate donor suitability. We have evaluated 82 kidneys that received a period of pulsatile preservation at our institution. Kidneys were from consecutive donors age > or = 42 years and were stratified into three high risk groups: donor age > or = 60 (48%), the presence of hypertension (52%), and IMPORT kidney (48%). All IMPORT kidneys were obtained through UNOS after the local center considered them unacceptable for transplant and none were 6-antigen match organs. Kidneys were discarded if they failed to have a FLOW > or = 70 ml/min or RR < or = 0.4. Twelve kidneys (15%) failed to meet these criteria and were discarded. All 12 kidneys were from donors age > or = 60 (p = 0.002). The average FLOW and RR of transplanted kidneys was 103 ml/min and 0.3283 respectively. Six of 69 (8.6%) transplanted organs required dialysis (ATN). No pump parameters predicted the development of ATN although 5 of 6 kidneys were IMPORTs. Recipient outcome data, including 72-hour urine output and day 10 serum Cr, were affected by organ risk group, but these did not impact on patient care.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1993

A randomized, prospective, double-blinded trial of cyclosporine vs. OG37-325 in cadaveric renal transplantation--a preliminary report.

The efficacy of cyclosporine is documented, but it has side effects that are troublesome. Another compound, OG37-325, has been identified that appears to have similar efficacy, but less nephrotoxicity. This study was designed to address the benefits and toxicities of cyclosporine and OG37-325 in a prospective, randomized, double-blinded trial in cadaveric renal transplant recipients. The preliminary results demonstrate similar outcomes in terms of patient and graft survival, but suggest less nephrotoxicity in the OG37-325-treated patients. Longer follow-up will delineate the utility of OG37-325 in solid-organ transplantation.

Adult↗
PubMed1993

OKT3 for primary therapy of the first rejection episode in kidney transplants.

The improvement in one-year graft survival has allowed transplant centers to focus on long-term graft survival. A study of 665 primary cadaveric kidney transplants from a single center treated with cyclosporine demonstrated that patients did not develop chronic rejection if there was not an episode of acute rejection. This study is a retrospective review of 314 consecutive kidney transplants from a single center to determine if early, aggressive treatment of the first episode of acute rejection will improve graft survival without increasing recipient morbidity. The course of 314 consecutive kidney transplants performed during a 27-month period (245 CAD and 68 living-related) was studied. Demographic characteristics were equivalent between the two groups, and all patients received sequential quadruple immunosuppression using ALG and CsA. Patient and graft survivals at 2 years were 89.7% and 84%, respectively. At least one rejection episode occurred in 41% of the patients, one-half within 30 days of transplant. Rejection episodes were treated by oral prednisone taper, primary ALG or OKT3, or "rescue" therapy with ALG or OKT3. Graft survival in the 52 recipients treated with OKT3 for primary treatment of first rejection episode was 20% better than the 50 patients treated with PRED (P = 0.0847). Comparing the 39 recipients of primary CAD kidneys treated with primary OKT3 vs. 38 treated with PRED demonstrated a 32% improvement in 2-year graft survival (P = 0.033). There was no increase in second rejection episodes in patients treated with OKT3. Renal function was equivalent in patients with rejection regardless of type of antirejection therapy used. Of patients treated for rejection, 22% had symptomatic CMV infections, which were divided equally between the two groups. Eighty-two patients received a single course of OKT3, 28 received two courses, and 2 patients received OKT3 three times. Only two patients developed antimurine antibodies that required abandoning OKT3 for the treatment of rejection. This study clearly demonstrates that the early use of OKT3 as primary treatment of rejection results in significant improvement of 2-year graft survival in recipients of first CAD kidney transplants. There is no increase in episodes in CMV in patients treated with OKT3 as primary therapy and no increase in patient mortality. Early use of OKT3 does not prevent or decrease incidence of subsequent rejection episodes. Renal function in surviving grafts is not improved in patients treated with OKT3 vs. PRED.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗