Iwaki, Y

Iwatsuki, S

Kano, T

Klintmalm, G

Koep, L

Schröter, G

Starzl, TE

Terasaki, PI

Weil, R

English

PubMed

Schroter, GP

Name not available

Determinants of effectiveness of thoracic duct drainage for primary cadaver kidney transplantation

D-Scholarship@Pitt

Determinants of Effectiveness of Thoracic Duct Drainage for Primary Cadaver Kidney Transplantation G. Klintmalm, S. Iwatsuki, T. Kano, Y. Iwaki, P. I. Terasaki, G. Schroter, L. Koep, R. Weil, and T. E. Starzl I N PREVIOUS publications,I,2 it was suggested that thoracic duct drainage (TOO) should be used for at least 28 days before renal transplantation in order to achieve the maximum benefit of this lymphoid-depleting procedure. Further expe-rience has reinforced this conclusion. The lines of evidence are as follows. KIDNEY AND PATIENT SURVIVAL In Fig. 1 are shown the kidney survival curves in primary cadaveric recipients who were treated with: (1) azathioprine and pred-nisone to which an ineffective ALG was often added; (2) the same, but with TOO starting on the day of transplantation; (3) the same, with TOO treatment prior to transplantation for 17-27 days; and (4) the same, with TOO pretreatment 28 days or more. Kidney survival was better in all TOO groups than in patients treated with conven-tional immunosuppression alone. The best results were achieved with pretreatment of ;:0:28 days (Fig. 1). The 22 patients who were pretreated ;:0:28 days had only a single rejec-tion (4.5%) in the first 3 months. The actual as well as actuarial patient mortality was not greater in the TOO series than in the retrospective controls, and indeed it was slightly less (Fig. 2). HUMORAL ANTIBODIES AFTER TRANSPLANTATION Warm anti-T and/or anti-B-Iymphocyte antibodies3 in response to transplantation were measured in 19 patients who were pretreated for 16-27 days and in the 22 From the Department of Surgery. Denver Veterans Administration Medical Center and the School of Medi-cine of the University of Colorado Health Sciences Center, Denver, Colo. and the Department of Surgery. School of Medicine, University of California. Los Angeles. Center for the Health Sciences. Los Angeles, Calif. Supported in part by research projects from the Veter-ans Administration; by USPHS Grants AM-17260 and AM-0777l; and by Grants RR-00051 and RR-00069 from the General Clinical Research Centers Program of the Division of Research Resources, National Institutes of Health. Reprint requests should be addressed to T. E. Starzl. Department of Surgery. University of Pittsburgh. 1084 Scaife Hall. Pittsburgh, Pa. 15261. © 1981 by Grune & Stratton. Inc. 0041-1 345/81/1 301 ... {)] 24$01.00/0 THORACIC DUCT DRAINAGE (TOO) VS. CONTROL PRIMARY CADAVERIC RENAL GRAFT SURVIVAL Fig. 1. One-year actuarial graft survival. TOO pretreat-ment for 28 days or more significantly differs from con-trols at 3, 6, and 12 months. TOO pretreatment of less than 28 days and contemporaneous TOO do not differ from con-trols. The control group con-sists of 51 consecutive retro-spective controls. 100 80 ACTUARIAL 60 GRAFT SURVIVAL '" 40 20 Transplantation Proceedings, Vol. XIII, No.1 (March). 1981 ~ 22 22 , TOO ~OK DAYS " 25 ~-o--------onzOO '1::............ 2. 9 - - __ -_-.:: __ -...:--=-__ ::: _____ ~!~I~<OU DAYS 19 - - - - - 2' CONTEMPORANEOUS TOO ~"--------~~:~oli p<O.05 0---0 -3 p<O.05 0---0 -6 MONTHS 51 n 2 51 p<O.OI 0--0 -12 537 538 THORACIC DUCT DRAINAGE (TOO) PRETREATMENT "'5. CONTROL PRIMARY CADAVERIC GRAFT PATIENT SURVIVAL 100 BO A~:~f~~~Ai 60 SURVIVAL ... 40 20 12 MONTHS Fig. 2. Side effects from TOO include occasional bacteremia. chylothorax. and rarely wound infection. However. TOO does not affect the mortality. patients who had TOO for 28 days or more before transplantation. Compared to recip-ients with TOO pretreatment ~OU days, patients with shorter periods of preparation were still draining large numbers of lympho-cytes in the last 5 days preceding transplanta-tion, retained a strong capability to produce KLiNTMALM ET AL. warm antibodies, and had a high incidence of rejection (Fig. 3). CONCLUSION The foregoing results explained why the primary cadaveric kidneys survived at such a high rate in patients conditioned by TOO for 4 weeks or longer. The immunodepressive effect of TOO was not fully established until the full 4 weeks. The same conclusion about the time curves of TOO effectiveness has been reached by Machleder and Paulus4 by immu-nologic tests in patients being treated for autoimmune diseases. REFERENCES I. Starzl TE, Wei I R III. Koep LJ, et al: Ann Surg 190:474,1979 2. Starzl TE, Wei! R III, Koep LJ, et al: Surg Gynecol Obstet 149:815, 1979 3. Terasaki PI, Bernoco D, Park MS, et al: Am J elin Pathol 69: 1 03, 1978 4. Machleder HI, Paulus H: Surgery 84:157,1978 NUMBER OF LYMPHOCYTES REMOVED BY TOO LAST 5 DAYS PRIOR TO TRANSPLANT n ][ ,0-20.,0' c::::::J No. of patients G::J No_ of patients with rejections _ No. of patients with graft losses from rejection Rejection: I v s. m p < 0.01 IV5 n p<O.OI 17 n 1Il 17 17 I CJ 2:20.,0' 10-20.,0' c:J No. of patients c:::J No. of patients developinq BW/TW antibodies after transplant ~ No. of patients with BW/TW antibodies before and after transplant Patients developinQ BW/TW after transplant: I v s.II p < 0.1 Iv •. ][ p < 0.01 ][vs. m n.s· Fig. 3. The incidence of rejection and graft losses from rejection within 3 months aftar transplantation in group I. characterized by the largest number of lymphocytes still being present in the last 5 days before transplantation; 6/7 patients experienced rejection and 2 grafts were lost. In group II. characterized by removal of intermediate numbers of lymphocytes in this pretransplantation period. 6/17 patients had rejections and 3 grafts were lost. In group III. characterized by the least number of residual lymphocytes. only 2/17 patients experienced rejections and only 1 graft was lost. The incidence of rejection within 3 months between groups I and III and between groups I and II differs significantly (p < 0.01 ). In group I. one patient had antibodies before and 6 developed antibodies after transplantation. In group II. 2 patients had antibodies before and 7 developed antibodies after transplantation. In group III. one patient had antibodies before and 3 developed antibodies after transplantation. The ability to form B-warm andl or T -warm antibodies between groups I and II is not quite significant (p < 0.1 ); but between groups I and III a significance exists (p < 0.01). There is no statistically significant difference between groups II and III. BW. warm anti-B-Iymphocyte antibodies; TW. warm anti-T -lymphocyte antibodies. 

Determinants of effectiveness of thoracic duct drainage for primary cadaver kidney transplantation.

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Determinants of effectiveness of thoracic duct drainage for primary cadaver kidney transplantation.

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