1376
8. Brinton
GS, Topping TM, Hyndiuk RA, Aaberg TM, Reeser FH, Abrams GW. Post-traumatic endophthalmitis. Arch Ophthalmol 1984; 102: 547-50.
Bohigian GM, Olk RJ. Factors associated with poor visual results in endophthalmitis. Am J Ophthalmol 1986; 101: 323-34. 10. Driebe WT, Mandelbaum S, Forster RK, Schwartz LK, Culbertson WW. Pseudophakic endophthalmitis: diagnosis and management. Ophthalmology 1986; 93: 442-47. 11. Olson JC, Flynn HW Jr, Forster RK, Culbertson WW. Results in the treatment of post-operative endophthalmitis. Ophthalmology 1983; 90: 9.
692-99. 12.
Rowsey JJ, Newsom DL, Sexton DJ, Harms WK. Endophthalmitis: current approaches. Ophthalmology 1982; 89: 1055-66.
13. Gleisher
DA, Welch RB. Late aseptic endophthalmitis after Am J Ophthalmol 1973; 75: 769-73.
cataract
surgery.
14. Meltzer DW. Sterile hypopyon following intraocular lens surgery. Arch Ophthalmol 1981; 98: 100-04. 15. Allen HF. Symposium: postoperative endophthalmitis. Prevention of postoperative endophthalmitis. Ophthalmology 1978; 85: 386-89. 16. Cameron ME, Forster TDC. Endophthalmitis occurring after hospitalisation following cataract surgery. Ophthalmic Surg 1978; 9: 52-57. 17. Fisch A, Lafaix C, Salvanet A, Cherifi M, Meulemans A. Ofloxacin in human aqueous humor and lens. J Antimicrob Chemother 1987; 20: 453-54. 18. Salvanet A, Fisch A, Lafaix C, et al. Pefloxacin concentrations in human aqueous humour and lens. J Antimicrob Chemother 1986; 18: 199-201.
CLINICAL PRACTICE Renal
transplantation into abnormal lower urinary tract
Because doubts remain about the safety and efficacy of renal transplantation for patients with primary urological abnormalities, we have studied the outcome of transplantation in a large group of such patients. Between 1977 and 1989, 69 renal transplants were completed in 62 patients with abnormal lower urinary tracts (29 primary vesicoureteric reflux, 13 posterior urethral valves or bladder outflow obstruction, 6 vesicoureteric tuberculosis, 5 neuropathic bladders, and 9 miscellaneous causes). Graft survival in this urological group was similar to that in 150 allograft recipients (157 grafts) with end-stage renal failure of a non-urological cause. No aetiological subgroup had poorer graft survival than the others, although patients with recurrent urinarytract infections and a history of outflow obstruction tended to have worse graft function. 9 patients (10 transplants) had renal transplantation into a urinary diversion (8 ileal conduits, 1 rectal bladder). These patients had graft survival and renal function comparable with those of the whole urological group. We found no effect of immunosuppressive treatment (cyclosporin or azathioprine), type of kidney donor (living or cadaveric), or donor or recipient age on graft survival time or renal function. Thus, renal transplantation in patients with abnormal lower urinary tracts is safe and effective; patients with ileal conduits do well and have few substantial difficulties. Preoperative assessment of bladder emptying and urodynamics are important in these patients.
Introduction Renal
transplantation is the treatment of choice for end-stage renal failure, but doubts remain about the risks of transplantation when the patient has an abnormal lower
urinary tract.1 The normal bladder is a continent, sterile, low-pressure reservoir, which empties easily and completely. Any other form of urinary reservoir aims to environment. When these features are not achieved, complications are possible-sepsis and renal dysfunction are the most important. The long-term outcome of transplantation in patients with urinary diversion or bladder augmentation is still unknown.2,3 Our renal unit has a large proportion of patients with primary urological disease. We have studied the outcome of transplantation in this group. recreate
such
an
Patients and methods During the 12-year period of study (June 1, 1977, to May 31, 1989), 226 renal transplants were completed in our unit in 212 patients. In 62 (69 transplants) of these patients, the lower urinary tract was abnormal (urological group), defined as an abnormality of urinary drainage that was the primary cause of the renal failure. The demographic details of the urological group and the remaining patients (non-urological group) are shown in table i. The primary urological abnormalities in the 62 patients were: primary vesicoureteric (reflux nephropathy) in 29; posterior urethral valves or bladder outflow obstruction in 13; vesicoureteric tuberculosis in 6; neuropathic bladder in 5 (3 congenital, 2 acquired); and miscellaneous in 9, including bilateral obstruction of the pelviureteric junction, prune-belly syndrome, and bladder surgery for malignant disease. 9 patients (10 transplants) had some form of urinary diversion before transplantation: 8 had ileal conduits and 1 an isolated rectal bladder with a proximal colostomy. The original renal disease in these patients was neuropathic bladder secondary to spinal cord lesions in 2; neuropathic bladder after surgical trauma in 1; vesicoureteric tuberculosis in 2; and cyclophosphamide-induced bladder fibrosis, total cystectomy for rhabdomyosarcoma of bladder, prune-belly syndrome, and bladder-neck obstruction in 1 each. Before 1985, patients were treated with prednisolone and azathioprine (1-5-2-5 mg/kg daily; 77 patients); these form the ADDRESS Institute of Urology and Nephrology, University College London, UK (H S. Cairns, MRCP, B Leaker, MRCP, C R. J. Woodhouse, FRCS, C J Rudge, FRCS, Prof G H. Neild, FRCP). Correspondence to Prof G H Neild, St Philip’s Hospital, Sheffield Street, London WC2A 2EX, UK
1377
group. There was no policy of deliberate blood transfusion before transplantation, but because of the underlying disease it is likely that all the patients had received transfusions. Since the beginning of 1985,149 patients have received low-dose prednisolone and cyclosporin, initially 14 mg/kg body weight reducing to 3-6 mg/kg by 6 months. All these patients received at least one unit of blood before transplantation. Patients and allografts were all ABO-blood-group compatible. No attempt was made to match HLA antigens except that previously rejected antigens were avoided. Renal transplant surgery used standard techniques. Since 1985, all transplant ureters have been kept open with a 6 French gauge stent, which is removed cystoscopically after 3 months unless there is a clinical indication, such as repeated urinary infections, for earlier removal. Actuarial graft survival was calculated and differences among groups compared by the log-rank test. Stepwise multiple regression analysis was used to study the importance of various features and treatments on graft survival time and renal function (logtransformed plasma creatinine); failed grafts were assigned a plasma creatinine of 999 umol/1 as an approximation of what the plasma creatinine would be if the patient were not on dialysis. Plasma creatinine concentrations of the various groups were compared by the Mann-Whitney U test.
azathioprine
Results Actuarial graft survival was significantly better in the urological patients than in the non-urological group at 1 year (figure, A; p = 0-008) but not at 5 years (p = 0-074). There were no significant differences in graft survival between the treatment subgroups within the urological group or between urological and non-urological patients who received each drug (figure, B). However, within the non-urological group, cyclosporin-treated patients had better graft survival than azathioprine-treated patients (figure, B; p = 003). Comparison of groups with cadaveric or live kidney donors showed no significant differences in graft survival between the urological and non-urological patients (figure, C; cadaveric p =0-08, live p =0-15). Among patients with functioning grafts, plasma creatinine concentrations 1 year and 5 years after transplantation were similar in the urological and nonurological groups (table I). Further separation into azathioprine-treated and cyclosporin-treated groups showed no, differences between the urological and nonurological treatment subgroups; the mean plasma creatinine concentrations of the azathioprine groups were lower than those of the cyclosporin groups 1 year after transplantation (urological p=003, non-urological p=0’04) but not at 5 years. TABLE I-DEMOGRAPHIC DETAILS OF PATIENT SUBGROUPS
Actuarial graft survival. A: B:
urological non-urological AU=azathioprine urological group; AN-U=azathioprine nonurological group; CU=cyclosporin urological group; CN-U =cyclosporin non-urological group. C: CDU=cadaveric-donor urological group; CDN-U=cadavericdonor non-urological group; LDU = live-donor urological group; LDNU live-donor non-urological group vs
=
Multiple regression analysis showed that type of immunosuppression, type of donor, urological or nonurological disease, and donor or recipient age had no significant effect on graft survival time or renal function (log-transformed plasma creatinine at 6 months after transplantation and at latest follow-up). The maximum multiple R was 0-3 (r2 0-05-0-10). 20 grafts in the urological group failed. 15 losses were secondary to biopsy-confirmed rejection--8 acutely or subacutely within 6 months of transplantation, 1 acutely after childbirth, and 6 late (7 to 60 months after transplantation) with features of chronic vascular rejection. In the other 5 patients, a graft biopsy sample showed no evidence of rejection; all 5 had inadequate bladder emptying and frequent urinary-tract infections. Detailed urodynamic studies were not done in all patients =
*Mean (SEM). tp
8. Brinton
GS, Topping TM, Hyndiuk RA, Aaberg TM, Reeser FH, Abrams GW. Post-traumatic endophthalmitis. Arch Ophthalmol 1984; 102: 547-50.
Bohigian GM, Olk RJ. Factors associated with poor visual results in endophthalmitis. Am J Ophthalmol 1986; 101: 323-34. 10. Driebe WT, Mandelbaum S, Forster RK, Schwartz LK, Culbertson WW. Pseudophakic endophthalmitis: diagnosis and management. Ophthalmology 1986; 93: 442-47. 11. Olson JC, Flynn HW Jr, Forster RK, Culbertson WW. Results in the treatment of post-operative endophthalmitis. Ophthalmology 1983; 90: 9.
692-99. 12.
Rowsey JJ, Newsom DL, Sexton DJ, Harms WK. Endophthalmitis: current approaches. Ophthalmology 1982; 89: 1055-66.
13. Gleisher
DA, Welch RB. Late aseptic endophthalmitis after Am J Ophthalmol 1973; 75: 769-73.
cataract
surgery.
14. Meltzer DW. Sterile hypopyon following intraocular lens surgery. Arch Ophthalmol 1981; 98: 100-04. 15. Allen HF. Symposium: postoperative endophthalmitis. Prevention of postoperative endophthalmitis. Ophthalmology 1978; 85: 386-89. 16. Cameron ME, Forster TDC. Endophthalmitis occurring after hospitalisation following cataract surgery. Ophthalmic Surg 1978; 9: 52-57. 17. Fisch A, Lafaix C, Salvanet A, Cherifi M, Meulemans A. Ofloxacin in human aqueous humor and lens. J Antimicrob Chemother 1987; 20: 453-54. 18. Salvanet A, Fisch A, Lafaix C, et al. Pefloxacin concentrations in human aqueous humour and lens. J Antimicrob Chemother 1986; 18: 199-201.
CLINICAL PRACTICE Renal
transplantation into abnormal lower urinary tract
Because doubts remain about the safety and efficacy of renal transplantation for patients with primary urological abnormalities, we have studied the outcome of transplantation in a large group of such patients. Between 1977 and 1989, 69 renal transplants were completed in 62 patients with abnormal lower urinary tracts (29 primary vesicoureteric reflux, 13 posterior urethral valves or bladder outflow obstruction, 6 vesicoureteric tuberculosis, 5 neuropathic bladders, and 9 miscellaneous causes). Graft survival in this urological group was similar to that in 150 allograft recipients (157 grafts) with end-stage renal failure of a non-urological cause. No aetiological subgroup had poorer graft survival than the others, although patients with recurrent urinarytract infections and a history of outflow obstruction tended to have worse graft function. 9 patients (10 transplants) had renal transplantation into a urinary diversion (8 ileal conduits, 1 rectal bladder). These patients had graft survival and renal function comparable with those of the whole urological group. We found no effect of immunosuppressive treatment (cyclosporin or azathioprine), type of kidney donor (living or cadaveric), or donor or recipient age on graft survival time or renal function. Thus, renal transplantation in patients with abnormal lower urinary tracts is safe and effective; patients with ileal conduits do well and have few substantial difficulties. Preoperative assessment of bladder emptying and urodynamics are important in these patients.
Introduction Renal
transplantation is the treatment of choice for end-stage renal failure, but doubts remain about the risks of transplantation when the patient has an abnormal lower
urinary tract.1 The normal bladder is a continent, sterile, low-pressure reservoir, which empties easily and completely. Any other form of urinary reservoir aims to environment. When these features are not achieved, complications are possible-sepsis and renal dysfunction are the most important. The long-term outcome of transplantation in patients with urinary diversion or bladder augmentation is still unknown.2,3 Our renal unit has a large proportion of patients with primary urological disease. We have studied the outcome of transplantation in this group. recreate
such
an
Patients and methods During the 12-year period of study (June 1, 1977, to May 31, 1989), 226 renal transplants were completed in our unit in 212 patients. In 62 (69 transplants) of these patients, the lower urinary tract was abnormal (urological group), defined as an abnormality of urinary drainage that was the primary cause of the renal failure. The demographic details of the urological group and the remaining patients (non-urological group) are shown in table i. The primary urological abnormalities in the 62 patients were: primary vesicoureteric (reflux nephropathy) in 29; posterior urethral valves or bladder outflow obstruction in 13; vesicoureteric tuberculosis in 6; neuropathic bladder in 5 (3 congenital, 2 acquired); and miscellaneous in 9, including bilateral obstruction of the pelviureteric junction, prune-belly syndrome, and bladder surgery for malignant disease. 9 patients (10 transplants) had some form of urinary diversion before transplantation: 8 had ileal conduits and 1 an isolated rectal bladder with a proximal colostomy. The original renal disease in these patients was neuropathic bladder secondary to spinal cord lesions in 2; neuropathic bladder after surgical trauma in 1; vesicoureteric tuberculosis in 2; and cyclophosphamide-induced bladder fibrosis, total cystectomy for rhabdomyosarcoma of bladder, prune-belly syndrome, and bladder-neck obstruction in 1 each. Before 1985, patients were treated with prednisolone and azathioprine (1-5-2-5 mg/kg daily; 77 patients); these form the ADDRESS Institute of Urology and Nephrology, University College London, UK (H S. Cairns, MRCP, B Leaker, MRCP, C R. J. Woodhouse, FRCS, C J Rudge, FRCS, Prof G H. Neild, FRCP). Correspondence to Prof G H Neild, St Philip’s Hospital, Sheffield Street, London WC2A 2EX, UK
1377
group. There was no policy of deliberate blood transfusion before transplantation, but because of the underlying disease it is likely that all the patients had received transfusions. Since the beginning of 1985,149 patients have received low-dose prednisolone and cyclosporin, initially 14 mg/kg body weight reducing to 3-6 mg/kg by 6 months. All these patients received at least one unit of blood before transplantation. Patients and allografts were all ABO-blood-group compatible. No attempt was made to match HLA antigens except that previously rejected antigens were avoided. Renal transplant surgery used standard techniques. Since 1985, all transplant ureters have been kept open with a 6 French gauge stent, which is removed cystoscopically after 3 months unless there is a clinical indication, such as repeated urinary infections, for earlier removal. Actuarial graft survival was calculated and differences among groups compared by the log-rank test. Stepwise multiple regression analysis was used to study the importance of various features and treatments on graft survival time and renal function (logtransformed plasma creatinine); failed grafts were assigned a plasma creatinine of 999 umol/1 as an approximation of what the plasma creatinine would be if the patient were not on dialysis. Plasma creatinine concentrations of the various groups were compared by the Mann-Whitney U test.
azathioprine
Results Actuarial graft survival was significantly better in the urological patients than in the non-urological group at 1 year (figure, A; p = 0-008) but not at 5 years (p = 0-074). There were no significant differences in graft survival between the treatment subgroups within the urological group or between urological and non-urological patients who received each drug (figure, B). However, within the non-urological group, cyclosporin-treated patients had better graft survival than azathioprine-treated patients (figure, B; p = 003). Comparison of groups with cadaveric or live kidney donors showed no significant differences in graft survival between the urological and non-urological patients (figure, C; cadaveric p =0-08, live p =0-15). Among patients with functioning grafts, plasma creatinine concentrations 1 year and 5 years after transplantation were similar in the urological and nonurological groups (table I). Further separation into azathioprine-treated and cyclosporin-treated groups showed no, differences between the urological and nonurological treatment subgroups; the mean plasma creatinine concentrations of the azathioprine groups were lower than those of the cyclosporin groups 1 year after transplantation (urological p=003, non-urological p=0’04) but not at 5 years. TABLE I-DEMOGRAPHIC DETAILS OF PATIENT SUBGROUPS
Actuarial graft survival. A: B:
urological non-urological AU=azathioprine urological group; AN-U=azathioprine nonurological group; CU=cyclosporin urological group; CN-U =cyclosporin non-urological group. C: CDU=cadaveric-donor urological group; CDN-U=cadavericdonor non-urological group; LDU = live-donor urological group; LDNU live-donor non-urological group vs
=
Multiple regression analysis showed that type of immunosuppression, type of donor, urological or nonurological disease, and donor or recipient age had no significant effect on graft survival time or renal function (log-transformed plasma creatinine at 6 months after transplantation and at latest follow-up). The maximum multiple R was 0-3 (r2 0-05-0-10). 20 grafts in the urological group failed. 15 losses were secondary to biopsy-confirmed rejection--8 acutely or subacutely within 6 months of transplantation, 1 acutely after childbirth, and 6 late (7 to 60 months after transplantation) with features of chronic vascular rejection. In the other 5 patients, a graft biopsy sample showed no evidence of rejection; all 5 had inadequate bladder emptying and frequent urinary-tract infections. Detailed urodynamic studies were not done in all patients =
*Mean (SEM). tp
