Study on optimized immunosuppression during the period of acute tubular necrosis following cadaveric renal transplantation

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We have carried out consecutive 152 kidney-a-allograftings (81 living-related, 71 cadaveric). A total number of 32 cadaver renal transplantations was Performed in the Period from 1987 to 1989. Postoperative acute tubular necrosis (ATN) was inevitable in our cadaveric kidney transplant patients because of harvesting from cardiac arrest donors. Analyzing our cases, we studied the optimized immunosuppression and appropriate patient management during ATN. The results are following. 1) Immunosuppression during ATN: The advent of cyclosporine (Cs) brought about the remarkable improvement of graft survival rate. Our cadaver graft survival rate became 77% after the Cs introduction. The Cs dose was adjusted according to Cs blood concentration trough levels and histological findings of needle biopsy tissue from the graft. As a marker of immunosuppression, the lymphocyte subset, OKT4/8, was useful; the ratio under 0.6 meant the over-immunosuppressed state. OKT3, a new antirejection agent, was clinically excellent.2) Management of recipients with ATN: Echo-guided needle biopsy of ATN grafts was very useful in the differential diagnosis among rejection, ATN and Cs-nephrotoxicity. Immunocytochemical study (DNA polvmerase- alpha ) of the specimen revealed the stages of recovering from ATN. Our new immunosuppression, lymphocytapheresis, was successfully applied to the treatment of steroid-resistent rejection. We tried to make the more safe and easy lymphocytapheresis system. The measuring of Cs blood concentration using FPIA method was easily and rapidly done at bedside. The positive relationship between Cs-nephrotoxicity and renin-aidosterone was suggested. Ganciclovir for CMV infection and Colony Stimulating Factor for leukopenia were effective. The possibility was shown that UW solution shortened the ATN period.