778
cryoglobulins. To prevent the formation of new immunoglobulins and antibodies low-dose corticosteroid therapy was started. 2 weeks later the patient left hospital with her S.L.E. in stable remission, clinically and on laboratory findings; bodies
or
her cold rash life.
was
in clinical
remission, for the first time in her
not
be recommended
B. K. SHURKALIN S. L. AGEYEV V. A. PITENOV R. M. BALABANOVA Z. S. ALEKBEROVA
Department of Hæmosorption, 2nd Moscow Medical Institute, Moscow, U.S.S.R.
PEPTIC ULCER AFTER RENAL TRANSPLANTATION
SIR,-In discussing peptic ulcer after renal transplantation (Feb. 17, p. 366) you omit important facts and make some
questionable recommendations. There is evidence that high frequency and mortality from upper gastrointestinal complications after transplantation is associated with high dose maintenance prednisolone (50-400 mg) in the early postoperative period.’ The simple measure of adopting a low dosage prednisolone regimen (20 mg) from the first day after operation is likely to greatly reduce this problem, and is an effective means of immunosuppression.2 We feel this point deserves greater emphasis. With regard to pre-transplant gastric assessment, it is true that dyspeptic symptoms, pentagastrin tests, and barium meal examinations are of limited value. However, the combined use of endoscopic and radiological investigation before operation showed ulcer craters or scars in 34 of 131 (26%) patients accepted for the Belfast transplant programme.’ While the influence of post-transplant corticosteroids may add some de novo ulceration, the size of this contribution is likely to be small as judged from the figures given by Conn and Blitzer.3 Most "acute" ulcers after renal transplantation are therefore likely to represent steroid-induced exacerbations of pre-existing disease. Screening of the transplant candidate thus will identify the majority of at-risk patients likely to benefit from prophylactic treatment. Some ursemic patients with ulcer have acid hypersecretion and plasma gastrin levels in the ZollingerEllison range, and in such patients ulcer disease may run a severe clinical course;4 there is, however, little use for routine measurement of gastric acid or plasma gastrin. Gastric acid output may show minor short-term fluctuations after transplantation,5 but in the long-term the peak acid output shows a significant tendency to decline.6 This latter observation further strengthens arguments’ against prophylactic ulcer surgery before transplantation, but we do not believe that the correct alternative instead is to give prophylactic cimetidine to all patients, as you suggest. Prevention of upper gastrointestinal complications in renal
transplant patients can be more logically achieved by pretransplant gastric assessment, administration of prophylactic cimetidine to those who have peptic ulcer, and use of a low
dosage prednisolone regimen. Cimetidine is not free from sideeffects, should only be given for specific indications, and can1.
Doherty, C. C., McGeown, 15, 361.
M. G. Proc. Eur.
Dialy. Transpl. Assoc. 1978,
2. McGeown, M. G. Lancet, 1973, i, 310. 3. Conn, H. O., Blitzer, B. L. New Engl. J. Med. 1976, 294, 473. 4. Doherty, C. C. M. D. thesis. 1978, Queen’s University of Belfast. 5. Chisholm, G. D., and others Br. med. J. 1977, i, 1630. 6. Doherty, C. C. Irish J. med Sc. 1978, 147, 376. 7. Doherty, C. C., O’Connor, F. A., Buchanan, K. D., Sloan, McGeown, M. G. Proc. Eur. Dialy. Transpl. Assoc. 1977, 14,
J., Ardill, J., 386.
routine third
drug for
renal
trans-
plant patients. Renal Unit, Belfast City Hospital, Belfast BT9 7AB
Plasmaperfusion through charcoal may make it possible to avoid the undesirable consequences of long-term corticosteroid therapy in such patients. Y. M. LOPUKHIN M. N. MOLODENKOV N. G. EVSEYEV
as a
CIARAN C. DOHERTY MARY G. MCGEOWN
RENAL TRANSPLANTATION IN DIABETICS
SIR,—Dr Deppermann and Professor Ritz (Jan. 6, p. 41) that the initial impressionl.2 that diabetes mellitus represented a specific indication for renal transplantation was not supported by a recent Scandinavian series3 and that the view of the Scandinavian workers is supported by recent reports from other transplant centres.4-6 Among the three literature
state
sources
cited, two were from this institution.4,6 interpretation of Deppermann and
I do not agree with the
Ritz of their results or with the conclusions they draw from our reported results. Workers here still believe that diabetes mellitus represents a specific indication for renal transplantation and that transplantation is superior to chronic hasmodialysis. Three-year patient survival is 85%, 74%, and 52% when sibling donors, parent or offspring donors, and cadaveric donors, respectively, are used.’ These results are similar to those reported by the Human Renal Transplant Registry for non-diabetic patients and comparable to those reported by the European Dialysis and Transplant Association for patients on hxmodialysis. Furthermore, the diabetic patient with a functioning graft has a greater chance for rehabilitation than has the patient on ha’modialysis. Thus, since survival-rates of diabetic patients on hæmodialysis remain dismal, renal transplantation of the diabetic patient with kidneys from living related or cadaveric sources remains the treatment of choice.6-8 Mayo Clinic,
Rochester,
Minnesota 55901, U.S.A.
HORST ZINCKE
STREPTOCOCCUS FÆCALIS URINARY-TRACT INFECTION AND RENAL-ALLOGRAFT REJECTION
SIR,-We were intrigued by the report of Byrd et a1.9 of an association between Streptococcus fcecalis urinary infection and graft rejection in kidney transplantation. This prompted us to look at our own data-the records of 140 patients receiving primary cadaver kidneys between 1971 and 1975. Complete data could not be obtained in 3 patients only, leaving 137 for analysis. We arbitrarily defined Strep. fcecalis urinary infection as >105 organisms/ml in at least one midstream urine specimen. 19 patients had Strep. fcecalis urinary infection in the first month after transplantation. 8 further patients had infections in months 2-12. 110 patients did not have a Strep. fcecalis infection in the first year after transplantation. Of those graft recipients with proven Strep. fa-calis urinary infection in the first postoperative month, 7/19 (37%) had 1.
Kjellstrand, C. M., Simmons, R. L., Goetz, F. C., Buselmeier, T. J., Shideman, J. R., Hartitzsch, V. B., Najarian, J. S. Lancet, 1973, ii, 4. 2. Kjellstrand, C. M., Shideman, J. R., Simmons, R. L., Buselmeter, T. J., Hartitzsch, V. V., Goetz, F. C., Najarian, J. S. Kidney Int. 1974, 6, suppl. p. 15. 3. Joint Scandinavian Report Lancet, 1978, ii, 915 4. Mitchell, J. C. Mayo Clinic Proc. 1977, 52, 281. 5. Totten, M. A., Izenstein, B., Gleason, R. E., Kassissieh, S. D, Libertino, J. A., D’Elia, J. A. Kidney Int. 1977, 12, 492. 6. Zincke, H., Woods, J. E., Palumbo, P. J., Leary, F. J., Johnson, W. J. J. Am med. Ass. 1977, 237, 1101. 7. Zincke, H., Woods, J. E., Sterioff, S., Johnson, W. J., Palumbo, P. J, Mitchell, J. C., Frohnert, P. P., Anderson, C. F., Service, F. J., Leary, F J Transplantation Proc. (in the press). 8. Woods, J. E., and others. Lancet, 1972, ii, 795. 9. Byrd, L. H., Cheigh, J. S., Stenzel, K. H., Tapia, L., Aronian, J, Rubin, A. L. Lancet, 1978, ii, 1167.
cryoglobulins. To prevent the formation of new immunoglobulins and antibodies low-dose corticosteroid therapy was started. 2 weeks later the patient left hospital with her S.L.E. in stable remission, clinically and on laboratory findings; bodies
or
her cold rash life.
was
in clinical
remission, for the first time in her
not
be recommended
B. K. SHURKALIN S. L. AGEYEV V. A. PITENOV R. M. BALABANOVA Z. S. ALEKBEROVA
Department of Hæmosorption, 2nd Moscow Medical Institute, Moscow, U.S.S.R.
PEPTIC ULCER AFTER RENAL TRANSPLANTATION
SIR,-In discussing peptic ulcer after renal transplantation (Feb. 17, p. 366) you omit important facts and make some
questionable recommendations. There is evidence that high frequency and mortality from upper gastrointestinal complications after transplantation is associated with high dose maintenance prednisolone (50-400 mg) in the early postoperative period.’ The simple measure of adopting a low dosage prednisolone regimen (20 mg) from the first day after operation is likely to greatly reduce this problem, and is an effective means of immunosuppression.2 We feel this point deserves greater emphasis. With regard to pre-transplant gastric assessment, it is true that dyspeptic symptoms, pentagastrin tests, and barium meal examinations are of limited value. However, the combined use of endoscopic and radiological investigation before operation showed ulcer craters or scars in 34 of 131 (26%) patients accepted for the Belfast transplant programme.’ While the influence of post-transplant corticosteroids may add some de novo ulceration, the size of this contribution is likely to be small as judged from the figures given by Conn and Blitzer.3 Most "acute" ulcers after renal transplantation are therefore likely to represent steroid-induced exacerbations of pre-existing disease. Screening of the transplant candidate thus will identify the majority of at-risk patients likely to benefit from prophylactic treatment. Some ursemic patients with ulcer have acid hypersecretion and plasma gastrin levels in the ZollingerEllison range, and in such patients ulcer disease may run a severe clinical course;4 there is, however, little use for routine measurement of gastric acid or plasma gastrin. Gastric acid output may show minor short-term fluctuations after transplantation,5 but in the long-term the peak acid output shows a significant tendency to decline.6 This latter observation further strengthens arguments’ against prophylactic ulcer surgery before transplantation, but we do not believe that the correct alternative instead is to give prophylactic cimetidine to all patients, as you suggest. Prevention of upper gastrointestinal complications in renal
transplant patients can be more logically achieved by pretransplant gastric assessment, administration of prophylactic cimetidine to those who have peptic ulcer, and use of a low
dosage prednisolone regimen. Cimetidine is not free from sideeffects, should only be given for specific indications, and can1.
Doherty, C. C., McGeown, 15, 361.
M. G. Proc. Eur.
Dialy. Transpl. Assoc. 1978,
2. McGeown, M. G. Lancet, 1973, i, 310. 3. Conn, H. O., Blitzer, B. L. New Engl. J. Med. 1976, 294, 473. 4. Doherty, C. C. M. D. thesis. 1978, Queen’s University of Belfast. 5. Chisholm, G. D., and others Br. med. J. 1977, i, 1630. 6. Doherty, C. C. Irish J. med Sc. 1978, 147, 376. 7. Doherty, C. C., O’Connor, F. A., Buchanan, K. D., Sloan, McGeown, M. G. Proc. Eur. Dialy. Transpl. Assoc. 1977, 14,
J., Ardill, J., 386.
routine third
drug for
renal
trans-
plant patients. Renal Unit, Belfast City Hospital, Belfast BT9 7AB
Plasmaperfusion through charcoal may make it possible to avoid the undesirable consequences of long-term corticosteroid therapy in such patients. Y. M. LOPUKHIN M. N. MOLODENKOV N. G. EVSEYEV
as a
CIARAN C. DOHERTY MARY G. MCGEOWN
RENAL TRANSPLANTATION IN DIABETICS
SIR,—Dr Deppermann and Professor Ritz (Jan. 6, p. 41) that the initial impressionl.2 that diabetes mellitus represented a specific indication for renal transplantation was not supported by a recent Scandinavian series3 and that the view of the Scandinavian workers is supported by recent reports from other transplant centres.4-6 Among the three literature
state
sources
cited, two were from this institution.4,6 interpretation of Deppermann and
I do not agree with the
Ritz of their results or with the conclusions they draw from our reported results. Workers here still believe that diabetes mellitus represents a specific indication for renal transplantation and that transplantation is superior to chronic hasmodialysis. Three-year patient survival is 85%, 74%, and 52% when sibling donors, parent or offspring donors, and cadaveric donors, respectively, are used.’ These results are similar to those reported by the Human Renal Transplant Registry for non-diabetic patients and comparable to those reported by the European Dialysis and Transplant Association for patients on hxmodialysis. Furthermore, the diabetic patient with a functioning graft has a greater chance for rehabilitation than has the patient on ha’modialysis. Thus, since survival-rates of diabetic patients on hæmodialysis remain dismal, renal transplantation of the diabetic patient with kidneys from living related or cadaveric sources remains the treatment of choice.6-8 Mayo Clinic,
Rochester,
Minnesota 55901, U.S.A.
HORST ZINCKE
STREPTOCOCCUS FÆCALIS URINARY-TRACT INFECTION AND RENAL-ALLOGRAFT REJECTION
SIR,-We were intrigued by the report of Byrd et a1.9 of an association between Streptococcus fcecalis urinary infection and graft rejection in kidney transplantation. This prompted us to look at our own data-the records of 140 patients receiving primary cadaver kidneys between 1971 and 1975. Complete data could not be obtained in 3 patients only, leaving 137 for analysis. We arbitrarily defined Strep. fcecalis urinary infection as >105 organisms/ml in at least one midstream urine specimen. 19 patients had Strep. fcecalis urinary infection in the first month after transplantation. 8 further patients had infections in months 2-12. 110 patients did not have a Strep. fcecalis infection in the first year after transplantation. Of those graft recipients with proven Strep. fa-calis urinary infection in the first postoperative month, 7/19 (37%) had 1.
Kjellstrand, C. M., Simmons, R. L., Goetz, F. C., Buselmeier, T. J., Shideman, J. R., Hartitzsch, V. B., Najarian, J. S. Lancet, 1973, ii, 4. 2. Kjellstrand, C. M., Shideman, J. R., Simmons, R. L., Buselmeter, T. J., Hartitzsch, V. V., Goetz, F. C., Najarian, J. S. Kidney Int. 1974, 6, suppl. p. 15. 3. Joint Scandinavian Report Lancet, 1978, ii, 915 4. Mitchell, J. C. Mayo Clinic Proc. 1977, 52, 281. 5. Totten, M. A., Izenstein, B., Gleason, R. E., Kassissieh, S. D, Libertino, J. A., D’Elia, J. A. Kidney Int. 1977, 12, 492. 6. Zincke, H., Woods, J. E., Palumbo, P. J., Leary, F. J., Johnson, W. J. J. Am med. Ass. 1977, 237, 1101. 7. Zincke, H., Woods, J. E., Sterioff, S., Johnson, W. J., Palumbo, P. J, Mitchell, J. C., Frohnert, P. P., Anderson, C. F., Service, F. J., Leary, F J Transplantation Proc. (in the press). 8. Woods, J. E., and others. Lancet, 1972, ii, 795. 9. Byrd, L. H., Cheigh, J. S., Stenzel, K. H., Tapia, L., Aronian, J, Rubin, A. L. Lancet, 1978, ii, 1167.
