Search

Objectives--To determine the use of renal replacement therapy by ethnic origin and to ascertain the variation in provision of such therapy and to relate this to the distribution of ethnic […]

Over the past 10 years, the care of the kidney transplant patient has been modified. This modification has included changes in drugs used to suppress graft rejection, treatment and prevention of infections, indications for transplant and modifications of the surgical technique, and improvements in anesthesia and intensive care. A study was undertaken at one hospital to evaluate the effect of these changes on both the rate and cause of rejection of the transplanted kidney. Outcomes of patients treated during the 1970s and those treated during the 1980s were compared. During the 1970s there were 1,012 patients who received kidneys; in the 1980s 1,384. There were 355 recipients who were diabetic in the 1970s and 628 diabetic recipients in the 1980s. The source of the kidney was a living donor for 617 of the 1970s patients and for 740 of the 1980s patients. Overall patient survival increased significantly. At one year, patient survival was 94 percent in the 1980s, compared with 86 percent in the 1970s; five-year survival was 84 percent versus 69 percent; 10-year survival was 68 percent versus 57 percent. Survival of the transplanted kidney also increased during the 1980s. These increases in occurred in spite of a higher percentage of recipients who were diabetic and who received a cadaver organ. The gains observed in the 1980s in graft survival were due mainly to a lower incidence of acute organ rejection and fewer infections. The two leading causes of poor outcomes, chronic rejection and death due to cardiovascular (heart and blood-vessel problems), showed little if any improvement. These are the two areas of challenge for the 1990s. (Consumer Summary produced by Reliance Medical Information, Inc.)

Chronic renal (kidney) failure in infants has been associated with severe neurologic and growth retardation. Treatment of renal failure in infants and neonates (under one month of age) is much more hazardous than treatments carried out in adults because the younger patients require modifications in kidney transplantation and dialysis therapy. (Dialysis removes toxins and other wastes that are normally excreted by the kidneys.) Infants usually receive kidney transplants to prevent growth retardation and to promote normal neurologic development. Treatment results are presented for 23 infants, 18 of whom were less than one month old. All the children required peritoneal dialysis before the age of 6 months. Various modifications were made in the dialysis procedure, including the use of modified silastic catheters, peel-away sheaths for percutaneous insertion (through the skin), automated dialysis cyclers, and removal of a large segment of omentum (thick layers of membrane lining the abdominal cavity and attached to the stomach) to prevent occlusion of the catheter. With these modifications there were no bowel perforations and the babies were successfully dialyzed for long periods of time. In 15 infants kidney failure was acute and resolved within two weeks of dialysis therapy; none of these babies required omentectomy. Eight babies had end-stage kidney disease and were prepared to undergo kidney transplantation. One baby died before this could be accomplished. Four transplants were performed, using a kidney donated from a living relative; three patients are awaiting a donor kidney. Good kidney function, growth and development have been noted in the infants who received kidney transplants. These results indicate that with adaptation of dialysis catheters and improvements in cycling, even the smallest newborn can be safely dialyzed. (Consumer Summary produced by Reliance Medical Information, Inc.)

Although kidney transplants have been performed for many years, there is controversy over the advisability of this procedure for young children with kidney failure or end-stage renal disease. Kidney failure in infants is associated not only with growth failure, but also with severe central nervous system disorders including progressive encephalopathy (abnormal structure or function of brain tissue), delayed development, microcephaly (small brain size) and seizures. If these infants are to survive and develop, they need early and aggressive intervention. Results are reported from the authors' experience in treating 75 infants less than two years old with kidney transplantation; 79 transplants were performed in these children. In 63 transplant operations, the donor was a living relative of the baby; 1 was not related; and 15 organs were obtained from cadavers (dead bodies). All the infants who received transplants were on or about to begin hemodialysis (a procedure in which wastes are removed from the blood using a machine). The transplants took place between 1965 and 1989, and 64 percent of the patients are alive with functioning kidneys. Since 1983, the one-year patient survival has been 95 percent, and the five-year survival has been 91 percent. Survival of the graft (donated organ) has been 86 percent at one year and 73 percent at five years. Patients who received immunosuppressive therapy with cyclosporine had 100 percent patient survival at one and five years, with graft survival of 96 percent at one year and 82 percent at five years. There was no difference in outcome between infants and older children. The most common cause of graft loss was rejection of the donated organ (15 patients). No graft rejection episode has been experienced by 52 percent of the transplant patients. Following transplantation, infant growth and development improved. It is recommended that living donors be used whenever possible. (Consumer Summary produced by Reliance Medical Information, Inc.)

Liver transplantation has improved the survival of children with end-stage liver disease, and is frequently the only curative treatment for these patients. More infants are being given liver transplants because of success with older children, but many transplant centers do not accept infants, even if they have life-threatening liver disease. The outcomes of liver transplantation in 17 infants under one year of age are reported. Of the 17 patients, 5 received more than one graft and a total of 26 liver transplantations were performed. Eleven patients survived to be discharged from the hospital, and 10 survived a year or more after hospital discharge. Four of the six patients who died following transplantation had required hospitalization prior to surgery. Surgical complications included blood clots in the hepatic artery (of the liver). Bacterial infections were common; two patients died as a result of complications associated with viral infections. Eleven patients experienced 18 episodes of graft rejection. One patient with rejection required a second transplant, but nine responded successfully to medical treatment. Although several patients had impaired kidney function following surgery, it was similar to their pretransplant status. Liver function is normal in all, but two of the surviving patients. Three of the older survivors have entered primary school and have no known deficits, while a fourth is developmentally delayed. The findings suggest that liver transplantation is a feasible treatment for children under one year of age, but should only be performed in medical facilities which are capable of managing these patients. The 64.7 percent survival rate of these infants, while not out of line, is less than the 75.8 percent survival of all 139 children who received liver transplants at this facility during a 5-year period. Careful selection of candidates and preoperative nutritional boosting are highly desirable. Further studies are needed to determine the risk factors of liver transplantation, which are specific to infants. (Consumer Summary produced by Reliance Medical Information, Inc.)

A major drawback in pediatric liver transplantation is the severe shortage of appropriately sized livers. Between 25 and 30 percent of children waiting for liver transplants die before an appropriate donor organ can be found. When liver transplantation possible, it offers the hope of long-term survival. A report is presented of 141 transplantations performed on 117 children using 54 reduced-size grafts. Ten children were under one year of age; 63 were between l and 3 years old; 21 were between 3 and 6; and, 23 were between 6 and 14 years old. The most common indication for transplant was biliary atresia, a congenital absence of one or more of the biliary structures, which affected 86 patients. Reduced-size livers were used in both urgent and elective cases. There were 83 full-size livers and 54 reduced-size livers transplanted; 4 were considered other technical variants. The one-year survival rate for the entire group was 77 percent; for the full-size liver recipients it was 82 percent, and for the reduced-size liver recipients it was 68 percent. Graft loss occurred with 26 (31 percent) of the full-size livers, and 24 (44 percent) of the reduced-size livers. Of the 74 children who had functioning livers six months after transplant, 67 percent had completely normal liver function tests, and 14 percent had only slightly abnormal liver tests. Use of this technique has reduced the mortality of children on the waiting list to 14 percent. It is concluded that the technique of reduced-size liver transplantation is safe and reliable and is recommended for treatment in urgent and elective cases. (Consumer Summary produced by Reliance Medical Information, Inc.)

A year after Congress issued a moratorium on the implementation of an HHS' rule to overhaul the organ distribution system, an amended final rule has been issued. Among other things, [...]

Issues concerning the problems faced by Asian people waiting for kidney transplants are discussed.

The issues surrounding tissue and organ transplantation include physiological, psychosocial, and ethical factors. The road from donor to recipient is tenuous. The process of organ and tissue allocation is based on an objective scoring system that fails to record the race of the patient. Black Americans, however, receive transplants half as often as whites. Women receive fewer transplants than men, and the poor receive transplants less often than higher income patients. There are some reasons for these apparent inequities. Women who have been pregnant may present crossmatching problems that make it more difficult to find an appropriate match. Blacks choose transplantation half as often as whites. In addition, about 20 percent of blacks can only be matched with another black. Since most organ donors are white, the option of transplantation may be further reduced for some black patients. However, there is serious speculation that organ and tissue transplantation may be infrequently discussed as a possible treatment with women, blacks and low-income patients. The critical care nurse can play an important role in issues related to minority transplantation. Specifically, the nurse can present the choice to the patient as a treatment option, and assist the patient and his or her family through the often lengthy process. The minority donor, as well as the minority recipient, should be counselled. The critical care nurse is in a particularly good position to provide the kind of information needed by the potential transplant candidate who should be enabled to make an informed, intelligent decision. (Consumer Summary produced by Reliance Medical Information, Inc.)

The death of baseball great Rod Carew's teen age daughter was one more tragedy in the story of people waiting in vain for tissues and organ. Michelle Carew waited for a bone marrow match. Blacks respond well to appeals for organs, but poor Blacks can not always afford the treatment.