Background Kidney transplantation (KTx) is the treatment of choice for children with end-stage renal disease (ESRD). Objective An update of 48 years of surgical experience with pediatric KTx (PKTx) is presented, and the results between recipients of organs from deceased donors (DDs) and living donors (LDs) are compared. Study design All patients younger than 18 years who underwent KTx between 1967 and 2015 were evaluated. Data from 540 PKTx operations (409 DD and 131 LD) were obtained from the transplant center database. Peri-operative data and graft and patient survival were analyzed in the DD and LD groups. Results Fewer recipients in the LD group underwent dialysis before PKTx than those in the DD group (50.8% in LD vs. 94.9% in DD, P < 0.001). The mean duration of dialysis (DD: 798 +/- 525 days vs. LD: 625 +/- 650 days, P = 0.03), time on the waiting list (DD: 472 +/- 435 days days vs. LD: 120 +/- 243 days, P < 0.001), cold ischemia time (CIT) (DD: 1206 +/- 368 min vs. LD: 140 +/- 63 min, P < 0.001), operation time, and hospital stay were lower in the LD group. Except for arterial stenosis, the rates of postoperative vascular and urological complications were not different between the two groups. The cumulative 25-year graft and patient survival rates were 46.4% and 84.1% in the DD group and 76.5% and 96.1% in the LD group, respectively. Discussion PKTx is the treatment of choice for children with ESRD. Graft quality has a direct impact on KTx outcome and rate of graft failure. Better HLA compatibility and shorter CIT reduce the impairment of graft function after LD PKTx. In addition, Establishment of an interdisciplinary approach using an individualized risk assessment and prevention model can improve PKTx outcomes. Conclusion Compared with DD PKTx, LD PKTx has better graft survival associated with a shorter duration of preceding dialysis, waiting time, and CIT and seems to be more beneficial for children. [GRAPHICS] .

Golriz, M.1; Mehrabi, A.1; Fonouni, H.1; Oweira, H.1; Santa, Castro E.1; Büchler, M. W.1; Tönshoff, B.1; Wiesel, M.1; Zeier, M.2; Schmidt, J.1 Author Information

Mehrabi, A.1; Golriz, M.1; Fonouni, H.1; Hafezi, M.1; Faridar, A.1; Esmaeilzadeh, M.1; Rad, Tahmasbi M.1; Jarahian, P.1; Wiesel, M.1; Tönshoff, B.1; Zeier, M.2; Schmidt, J.1 Author Information

Mehrabi, A.; Fonouni, H.; Golriz, M.; Esmaeilzadeh, M.; Rad, Tahmasbi M.; Hafezi, M.; Faridar, A.; Jarahian, P.; Santa, Castro E.; majlesara, A.; abbasi, S.; Büchler, M. W.; Wiesel, M.; Zeier, M.; Tönshoff, B.; Schmidt, J. Author Information

: A 52-year-old man on haemodialysis treatment for chronic glomerulonephritis also had a nephrotic syndrome, hypercholesterolaemia, severe arterial hypertension and peripheral vascular disease in stage IIb. He also was a heavy smoker. Following a nonspecific diarrhoeal illness, which caused haemoconcentration, he developed abdominal pain and fever. WBC count (29,000/microliter) and serum lactate level (18.2 mmol/l) were elevated, and there were clinical signs of lower abdominal peritonitis. Laparotomy revealed multiple ischaemic segments. The arteries were not thrombosed but had severe atheromatous changes. There is an increasing incidence of such nonocclusive intestinal ischaemia because there are more elderly people and more patients with high-risk factors among those requiring dialysis.

Urinary tract infection (UTI) is the most common post-transplant infection in renal transplant recipients. The relationship of plasma and urine cytokines with UTI after kidney transplantation has not yet been delineated and literature reports on cytokine and UTI are rare. In a retrospective study, we compared post-transplant plasma and urine cytokine levels of 132 outpatient renal transplant recipients with or without UTI. Soluble interleukin-1 receptor antagonist (sIL-1RA), IL-2, sIL-2R, IL-3, IL-4, IL-6, sIL-6R, IL-8, IL-10, transforming growth factor-beta2 (TGF-beta2), interferon-gamma (IFN-gamma), and tumor necrosis factor-alpha (TNF-alpha) levels were determined using commercially available enzyme-linked immunosorbent assay (ELISA) kits. We found gender-related urine cytokine patterns. Anti-inflammatory sIL-1RA was significantly higher in females than in males and this gender-related difference was more pronounced in bacteriuric (P < 0.0001) than in nonbacteriuric (P = 0.001) patients. Urine proinflammatory cytokines IL-6 (P = 0.001) and IL-8 (P = 0.007) were significantly higher in male patients with bacteriuria than in males without bacteriuria and sIL-2R (P = 0.001) and sIL-6R (P = 0.03) were significantly higher in males with leukocyturia than in males without leukocyturia. Bacteriuria in males was associated with higher doses of immunosuppressive drugs (P = 0.02). Male renal transplant recipients with UTI have a strong inflammatory cytokine response with activation of IL-6, IL-8, sIL-2R and sIL-6R producing cells, whereas female patients with UTI block the inflammatory response to UTI by production of sIL-1RA.

BACKGROUND:Interleukin (IL)-12-producing dendritic cells (IL-12+DC) polarize T helper (Th) differentiation toward Th1, whereas IL-10+DC induce Th differentiation toward Th2. We investigated DC and plasma cytokine patterns early and late after transplantation.METHODS:Twenty-five hospitalized renal-transplant recipients without acute rejection or infection early (<40 days) posttransplant, 32 symptom-free outpatients with long-term functioning transplants (2,762+/-2,423 days posttransplant), and 17 healthy controls were studied. The intracellular production of IL-12 and IL-10 in CD11c+ CD83+ CD40+ DC was measured in freshly obtained whole blood using four-color fluorescence flow cytometry. In addition, plasma cytokine levels were investigated.RESULTS:Early and late posttransplant patients had significantly lower proportions of IL-12+DC (early: P=0.001; late: P=0.034) and lower ratios of IL-12+/IL-10+DC (early: P=0.0001; late: P<0.0001) than healthy controls. IL-10+DC (P=0.0004) and IL-12+DC (P=0.002) increased with time posttransplant in association with dose reductions of cyclosporine (IL-10+DC: P=0.003; IL-12+DC: P=0.005), methylprednisolone (IL-10+DC: P<0.0001; IL-12+DC: P=0.001) and mycophenolate mofetil (IL-10+DC: P<0.0001; IL-12+DC: P=0.004). Both IL-10+DC and IL-12+DC were associated with low plasma IL-10 (IL-10+DC: P=0.010; IL-12+DC: P=0.011) and high plasma IL-6 (IL-10+DC: P=0.001; IL-12+DC: P=0.009). IL-10+DC were also associated with high plasma levels of IL-3 (P=0.003), interferon (IFN)-gamma (P=0.014), and IL-2 (P=0.058).CONCLUSION:IL-10+DC and IL-12+DC in peripheral blood are associated with time after transplantation and dosage of immunosuppression. IL-10+DC dominate late posttransplant in the presence of Th1 plasma cytokines (high IFN-gamma and IL-2), high IL-3, and low IL-10. These findings could be a reflection of immunoregulatory processes favoring long-term allograft acceptance.

P997 Aims: A domination of circulating plasmacytoid dendritic cells type 2 (DC2) late posttransplant was reported to be associated with good liver graft acceptance. In-vitro, both IL-10-producing myeloid and plasmacytoid DC were shown to polarize T helper cells (Th) into Th2 lymphocytes. Both exogenous and endogenous IL-10 affects the maturation of bone-marrow-derived dendritic cells in vitro and strongly influences T cell priming in vivo. Immature DC exposed to IL-10 for at least 2 days of culture showed a strongly reduced capacity to elicit a CD4+ T cell response in allogeneic MLR and it was shown that IL-10 converts immature DC into tolerogenic antigen presenting cells. We investigated in symptom-free renal transplant recipients early and late posttransplant whether IL-10-producing DC (IL-10+ DC) and Th might be conditioned towards anergy by high plasma IL-10. Methods: Plasma levels of soluble interleukin-1 receptor antagonist (sIL-1RA), IL-2, sIL-2R, IL-3, IL-4, IL-6, sIL-6R, IL-10, tumor-necrosis-factor-α (TNF-α), transforming-growth-factor-β2 (TGF-β2), and interferon-γ (IFN-γ) were studied in 25 hospitalized renal transplant recipients without acute rejection or acute infection early (x±1SD: 11±7 days) posttransplant, and in 32 symptom-free outpatients late (x±1SD: 2762±2423 days) posttransplant using standard ELISA. Intracellular IL-12 and IL-10 content of CD11c+CD83+CD40+ DC was measured in freshly obtained whole blood using four-color fluorescence flow cytometry. Proportions of CD11c+CD83+CD40+IL-12+ and CD11c+CD83+CD40+IL-10+ DC were compared with plasma cytokine levels. Results: Plasma IFN-γ (p=0.003) and IL-2 (p=0.01) were positively, plasma IL-10 (p=0.01) negatively associated with the posttransplant day, and high plasma IFN-γ and low plasma IL-10 were associated with low daily dosages of cyclosporine (IFN-γ: p=0.009; IL-10: p=0.0001), methylprednisolone (IFN-γ: p=0.002; IL-10: p=0.001), and mycophenolate mofetil (IFN-γ: p=0.08; IL-10: p=0.005). Th2 cytokines were found to dominate early posttransplant whereas during maintenance immunosuppression late posttransplant Th1 cytokines were high. It seems that IL-10+ DC are induced independent of IL-10 plasma levels. Both IL-12+ DC and IL-10+ DC were associated with low plasma IL-10 (IL-12+ DC: p=0.01; IL-10+ DC: p=0.01) and high plasma IL-6 (IL-12+ DC: p=0.009; IL-10+ DC: p=0.001). In addition, IL-10+ DC were associated with high plasma levels of IL-3 (p=0.003), IFN-γ (p=0.01), and IL-2 (p=0.05). The data suggest that IL-10+ DC dominate late posttransplant in association with high Th1 plasma cytokines. Plasma levels of IFN-γ and IL-10 were independent of graft function and serum creatinine levels in these patients with good graft outcome. Mycophenolate mofetil seems to affect TGF-β2 plasma levels because high plasma TGF-β2 was associated with low dose mycophenolate mofetil (p=0.01). Conclusion: High proportions of IL-10+ DC in transplant recipients with good graft outcome are associated with high IFN-γ, IL-2, and IL-3, and low IL-10 plasma levels. Strong immunosuppression is associated with a domination of Th2 and lower maintenance immunosuppression with a domination of Th1 cytokines in the plasma. Obviously, plasma cytokine levels do not affect the induction of IL-10+ DC late posttransplant implying that DC and Th are not conditioned towards anergy by high plasma IL-10 in outpatients.

Background: Recipients of living donor kidney transplantation hope for an improved physical well-being after transplant. Furthermore the patients and their relatives frequently expect an improvement in their psychological findings in consequence of the living related transplantation. The present study examines the psychosocial effects of living donor kidney transplantation for donors and recipients under successful as well as complicated circumstances.Material and methods: Based on 31 catamnestic interviews of recipient-donor couples and a content analysis of these interviews, hypotheses regarding the psychological requirements for a successful progression of a living kidney donation are deduced and put forward.Results: The aspiration for an improvement of psychological problems, particularly anxiety and depression, as an effect of transplantation can on the basis of the present results not be supported. Living donor kidney transplantation between close recipient and donors must not be regarded as a means to solve psychological problems and familial conflicts. An attitude characterized by realistic and modest expectations as well as relationships, which have been cleared of extreme conflicts prior to the transplantation could facilitate a favourable psychological progression.

A47 Aims: Although the majority of patients undergoing renal transplantation currently receive kidneys from cadaveric donors, living donors continue to be an important source of transplanted kidneys. Recipients of living donor kidneys demonstrate improved graft survival. We have reviewed our living donor nephrectomy experience over 35 years to analyze the donor and recipient morbidity and mortality rate. Methods: The operative complications and the long-term outcome of 219 living donated of all 1915 kidney transplantations before and after introduction of cyclosporine A were evaluated. Donor and graft complications as well as recipient complications and survival rate were investigated. Additionally, the findings of 16 laparoscopically operated living donors were compared to a group of 20 patients that underwent a conventional operation. Results: The overall recipient 3- and 5-year survival rates in the cyclosporine A era were 95% and 94%, respectively. Prior to the introduction of cyclosporine A, the overall recipient survival rates at 3 and 5 years were 84% and 84%, respectively. The overall graft survival rates were 92% and 85% for the cyclosporine A era compared to 68% and 60% before introduction of cyclosporine A, at 3 and 5 years, respectively. The patient and graft survival rate in the cyclosporine group were significantly higher than in the pre-cyclosporine group (log-rank: p = 0.0107 and p = 0.0003, respectively). Donor complications included pain at the incision site (35%), mild hypertension (27%), proteinuria (19%), urinary tract infection (11%), pneumothorax (5%), blood transfusion (3.5%), and wound infection (3%), with no mortalities. Our results showed longer operation, warm ischemia, and cold ischemia time in laparoscopically operated living donors than the conventional approach. There was no statistically significant difference in complications between both techniques. However, the hospitalization days and usage of analgesic medication in laparoscopy donors were lower than in the conventional approach. Conclusions: The results of the present analysis confirm an increase in patient and graft survival rates in the cyclosporine era compared to before its usage. Living donor nephrectomy, done through a conventional or laparoscopic approach, remains a valuable source of kidneys for transplantation with low complication rates.

We retrospectively reviewed our long-term experience with pediatric renal transplantation into a dysfunctional lower urinary tract to evaluate graft survival, function, and special urological complications. Between 1967 and March 2000, a total of 349 renal transplantations were performed in children younger than 18 years. Malformations of the lower urinary tract were the reasons for end-stage renal failure in 66 children (18.6%). The cause of urinary tract disorders included: meningomyelocele connected with neuropathic bladder (n = 4 transplantations); prune belly syndrome (n = 5 transplantations); VATER association (n = 2 transplantations); posterior urethral valves (n = 27 transplantations); and vesico-uretero-renal reflux (n = 28 transplantations). The majority of the patients underwent surgical interventions to preserve renal function or to prepare renal transplantation. The 1- and 5-year graft survival rate was evaluated with special reference to the underlying disease. The 1-year graft survival rate in all children with lower urinary tract malformations was 83.3%, compared with 88% for all children. In those children with vesico-ureteral reflux, it was 92.8% and in the children with Vater association and prune belly syndrome, it was 85.7%. One graft was lost in the children who had neurogenic bladder, so the 1-year graft survival rate was 75%. The worst 1-year graft survival rate was obtained for boys who had posterior urethral valves (1-year graft survival rate: 74%; 5-year graft survival rate: 62.9%). Concerning the 5-year graft survival rate, it was 70% for all children with malformations of the urinary tract. The best rate was obtained for children with reflux in the native kidneys (78.5%), followed by those with VATER association and prune belly syndrome. As an additional child with neurogenic bladder lost his graft, the 5-year graft survival rate was 50%. Pediatric renal transplantation into a dysfunctional bladder can be connected with high urological complication rates which may contribute to worse graft survival. The 1- and 5-year graft survival rate in children with malformations of the lower urinary tract is worse than in children without bladder dysfunction. We regarded a striking difference between graft survival and the urological disorders which led to renal insufficiency. We obtained the worst graft survival rates in children with posterior urethral valves which are usually connected with bladder emptying problems and dysfunctional voiding. Potential pediatric transplant recipients must be classified according to pathophysiological as well as anatomical abnormalities of the urinary tract and all urological problems have to be solved prior to transplantation. At our center, living donors are favored to plan transplantation of these children properly.

BACKGROUND:Kidney transplantation remains the most effective treatment for children with end-stage renal disease. We analysed data from the University of Heidelberg transplant programme to present our results on paediatric kidney transplantations over the past 35 years.METHODS:From 1967 to 2003, 354 paediatric kidney transplantations were performed at the University of Heidelberg. Data were obtained from the paediatric kidney transplantation records consisting of 291 (82%) cadaveric and 63 (18%) living donated transplants. Demographic data, family relationship of the living donors, surgical technique, immunosuppressive drugs, graft and patient survival rates were assessed.RESULTS:The mean age of cadaveric and living donors was 32.0+/-17.1 and 37.6+/-7.5 years, respectively. The family relationship of the living donors included the mother in 65% of cases, the father in 31%, and other relatives in 4%. In the last 4 years, the respective mean cold ischaemia time was 1.6+/-0.5 h for living donated and 13.5+/-4.1 h for cadaveric donors. The mean age of children who received kidneys from cadaveric and living donors was 11.3+/-4.5 and 10.4+/-4.5 years, respectively, with a male to female ratio of 57 to 43%. Overall patient survival rates were 95% after 1 year and 89% after 5 years. The patient 5 and 10 year survival rates for living donor renal transplantations were 95 and 95%, respectively. Graft survival rates improved since 1990 compared with the period prior to 1990: 82.5 vs 56.7% graft survival at 1 year and 82.5 vs 50% after 5 years (P = 0.03). Comparing the operating technique in a subgroup of our patients that received the same immunosuppressive regimen, anastomoses with the aorta and vena cava (51%, n = 31) were associated with a graft survival of 86.6 and 83.3% after 1 and 5 years, whereas anastomoses with iliac vessels (49%, n = 30) were associated with a graft survival of 55.8 and 51.6% after 1 and 5 years, respectively (P = 0.01).CONCLUSIONS:There has been a gradual improvement in our paediatric kidney transplantation results over time. Living donor paediatric kidney transplants have higher patient and better graft survival rates than cadaveric donor kidney transplants. Using the aorta and inferior vena cava for graft anastomosis, utilizing newer immunosuppressive drugs and implementing living kidney donation have positively affected the results of our paediatric kidney transplantations.

BACKGROUND:Although a majority of patients undergoing renal transplantation currently receive a cadaver kidney, living donors continue to be an important source of transplanted kidneys. Recipients of living donor kidneys demonstrate improved graft survival. To expand the pool of suitable organ donors an organ procurement programme of living donors has been developed over the past 35 years. We have reviewed our living donor nephrectomy experience over this period to analyse the donor and recipient peri- and postoperative morbidity and mortality rate.METHODS:We reviewed the operative complications and the long-term outcome of 219 living donated kidney transplantations before and after introduction of cyclosporine A. Donor and graft complications as well as recipient complications and survival rate were investigated. Additionally, the findings of 16 laparoscopically operated living donors were compared to a group of 20 patients who underwent a conventional surgery.RESULTS:The overall recipient 3 and 5 year survival rates in the cyclosporine A era were 95 and 94%, respectively. Prior to the introduction of cyclosporine A, the overall recipient survival rates at 3 and 5 years were 84 and 84%, respectively. The overall graft survival rates were 92 and 85% for the cyclosporine A era compared to 68 and 60% before introduction of cyclosporine A, at 3 and 5 years, respectively. The patient and graft survival rate in the cyclosporine group were significantly higher than in the pre-cyclosporine group (log-rank: P = 0.0107 and P = 0.0003, respectively). Donor complications included pain at the incision site (35%), mild hypertension (27%), proteinuria (19%), urinary tract infections (11%), pneumothorax (5%), blood transfusion (3.5%) and wound infection (3%), with no mortalities. Our results showed a longer duration of operation, and longer warm ischaemia and cold ischaemia times in laparoscopically operated living donors than those that were seen in the conventional approach. There was no statistically significant difference in complications between both techniques. However, the hospitalization days and usage of analgesic medication in laparoscopy donors were lower than in the conventional approach.CONCLUSIONS:Similar to previous studies the results of the present analysis confirm an increase in patient and graft survival rates in the cyclosporine era compared to before its usage. Living donor nephrectomy, done through a conventional or laparoscopic approach, remains a valuable source of kidneys for transplantation with low complication rates.

P1012 Aims: A domination of circulating plasmacytoid dendritic cells type 2 (DC2) late posttransplant was reported to be associated with good liver graft acceptance. In-vitro, both IL-10-producing myeloid and plasmacytoid DC were shown to polarize T helper cells (Th) into Th2 lymphocytes. We investigated proportions and ratios of circulating DC subpopulations producing IL-12 (IL-12+ DC) or IL-10 (IL-10+ DC) in renal allograft recipients and compared the results with graft function, acute rejection or infection, and daily doses of immunosuppressive drugs. Methods: Intracellular IL-12 or IL-10 content of CD11c+CD83+CD40+ DC was measured in freshly obtained whole blood using four-color fluorescence flow cytometry. Proportions of CD11c+CD83+CD40+IL-12+ and CD11c+CD83+CD40+IL-10+ DC were studied in 25 hospitalized renal transplant recipients without acute rejection or infection during the early posttransplant period (<40 days posttransplant; x±1SD: 11±7 days), 32 symptom-free outpatients with functioning renal transplants (>90 days posttransplant; x±1SD: 2762±2423 days), and 17 healthy controls. Results: Early and late posttransplant renal transplant recipients had significantly lower proportions of IL-12+ DC (early: p=0.001; late: p=0.03) and lower ratios of IL-12+/IL-10+ DC (early: p=0.0001; late: p<0.0001) than healthy controls. Proportions of IL-10+ DC were similar in patients and controls (p=n.s.). Outpatients had higher IL-10+ DC (p=0.0004) and lower IL-12+/IL-10+ DC ratios (p=0.05) than transplant recipients early posttransplant. IL-12+ DC (p=0.002) and IL-10+ DC (p=0.0004) increased with time posttransplant and in association with reductions of the daily doses of cyclosporine (IL-12+ DC: p=0.005; IL-10+ DC: p=0.003), methylprednisolone (IL-12+ DC: p=0.001; IL-10+ DC: p<0.0001) and mycophenolate mofetil (IL-12+ DC: p=0.004; IL-10+ DC: p<0.0001). Conclusion: Transplant recipients exhibit significantly lower proportions of circulating IL-12+ DC than healthy controls. The proportions of IL-12+ DC and IL-10+ DC are associated with time after transplantation and dosage of immunosuppression. IL-10+ DC were found to dominate late posttransplant, and this could be interpreted as an adaptation of the immune system to the graft and might be a useful indicator for lowering the dose of immunosuppression during graft quiescence.

Background. We and others have shown that expression of the cytotoxic T-lymphocyte effector gene perforin in the peripheral blood is a strong predictor of acute rejection in the early posttransplant period. In the present study we investigated whether interleukin (IL)-18, an immunostimulatory gene that up-regulates perforin-dependent cytotoxicity and promotes tissue damage through other noncytotoxic T-lymphocyte mechanisms alone or in combination with perforin gene expression, may serve as a better predictor of renal allograft rejection in the first weeks after transplantation. Methods. Peripheral blood was collected twice weekly, and gene expression was measured using real-time polymerase chain reaction. Results. Recipients with acute rejection (n=17) showed higher levels of perforin and IL-18 transcript on days 5 to 7, 8 to 10, and 11 to 13, compared with patients without rejection (n=37, P <0.01 in all cases). Rejection diagnosis using gene expression criteria was possible 1 to 32 days before traditional diagnosis (median 11 days). High specificity was associated with IL-18 expression (72%–93%), and high sensitivity was associated with perforin expression (63%–90%). Positive predictive value was optimized (78%–100%) by using combined up-regulation in both genes as a diagnostic criterion (double-positive). Using high expression in “either or both” genes as a diagnostic criterion yielded high sensitivity (82%–91%) and negative predictive value (91%–96%). Conclusions. Our data indicate that combined perforin and IL-18 gene expression measurements are useful tools for the recognition of graft rejection in its earliest stages. Serial measurements could be implemented as a monitoring system to identify patients at higher risk of rejection, making them candidates for biopsy or prophylactic increases in immunosuppression.

BACKGROUND:In order to avoid psychological complications in living-donor transplantation, careful evaluation and consultation of the donor-recipient system is necessary. This article describes the Heidelberg consultation procedure before and after transplantation. This approach emphasizes close collaboration between physician and psychologist in joint interviews.METHODS:Consultations focus on family genogram, the history of the donation idea; stability and balance of relationship; expectations; hesitations and doubts; discussion of complications; previous hospital experiences; the offer to provide crisis intervention when needed.RESULTS:In 20% of all cases, unresolved problems appear. These include: unilaterally dependent relationships; unrealistic hopes for change; anxious avoidance to reflect complications; lack of medical information; risky health behaviour; negative experiences with hospitals. When properly consulted, half of these couples resign from transplantation.CONCLUSIONS:Close physician-psychologist collaboration adds significant value to a 'psychologist-only' consultation. Discussing hesitations and concerns strengthens confidence in the professional transplantation system. Access to post-transplant consultation needs further improvement.

Background. Differences in early posttransplant immunologic responses between living donor (LDT) and cadaver donor transplant (CDT) recipients have not been thoroughly studied. This is the first study comparing lymphocyte subpopulations and plasma levels of different cytokines, soluble cytokine receptors, cytokine receptor antagonists, and neopterin during the first 2 posttransplant weeks.Patients and Methods. Lymphocyte subpopulations (CD3, CD4, CD8, CD16, CD19, and CD25) and plasma levels of soluble (s) interleukin(IL)-1 receptor antagonist (RA), EL-2, sIL-2R, IL-3, IL-4, IL-6, sIL-6R, IL-8, IL-10, transforming growth factor-beta(2), tumor necrosis factor-alpha, interferon-gamma, and neopterin were studied in 52 CDT and 33 LDT recipients 1 to 2,4 to 6, and 8 to 10 days after transplantation.Results. The most impressive finding was a consistently higher neopterin plasma level in CDT than LDT recipients. Although plasma neopterin decreased during the second posttransplant week in both groups (CDT, P=0.0001; LDT, P=0.001), the difference in plasma neopterin levels 8-10 days after transplantation was highly significant (P=0.005). In contrast, LDT had consistently higher sIL-1RA plasma levels during the first 2 posttransplant weeks. Whereas sIL-1RA plasma levels decreased in both groups during the first posttransplant week (CDT, P=0.001; LDT, P=0.005), they increased during the second posttransplant week in LDT (P=0.02) but remained stable and low in CDT recipients. Eight to ten days after transplantation, the difference was highly significant (P=0.002).Conclusion. These data suggest that transplantation of CDT is associated with strong monocyte-macrophage activation with consistently high neopterin plasma levels, whereas the effect of inflammatory cytokines seems to be down-regulated in LDT recipients by an increased release of antiinflammatory sIL-1RA.

With the introduction of mycophenolate mofetil (MMF) in renal transplantation, acute rejection episodes diminished and short-term graft survival improved. Better graft outcome, however, is followed by several surgical complications attributed to MMF Patients with risk factors (adiposity, diabetes mellitus, advanced age) show an increased rate of healing by second intention. We treated two patients with the vacuum sealing technique so that after 15 days a secondary suture became possible in each case. To date the vacuum sealing technique has been used mainly in traumatology, abdominal surgery, surgery for acute infections of soft tissue and bone, and problem wounds with reduced wound-healing capacity (chronic leg ulcer). This article presents two cases of successful application of the vacuum sealing technique in renal transplantation after prolonged wound healing.

Zusammenfassung Seit Einführung des Immunsuppressivums Mycophenolat-Mofetil (MMF) in der De-novo-Nierentransplantation werden bei Risikopatienten (Adipositas permagna, Diabetes mellitus, Old-for-old-Programm und hohes Alter) zunehmend ausgeprägte Wundheilungsstörungen beobachtet. Wir behandelten 2 Patienten mit der Vakuumversieglungstechnik, sodass jeweils nach 15 Tagen ein sekundärer Wundverschluss möglich wurde. Bis dato wurde die Vakuumversieglung hauptsächlich in der Traumatologie und Bauchchirurgie bei akuten Weichteil-, Knocheninfektionen und bei Problemwunden mit reduzierter Wundheilungskapazität (Ulcera cruris) eingesetzt. Wir berichten über den erfolgreichen Einsatz der Vakuumversieglung bei 2 nierentransplantierten Patienten mit ausgedehnten Wundheilungsstörungen.