Background. The Eurotransplant Senior Program (ESP) was launched in 1999, targeted to increase the supply of donor kidneys to the elderly. This program requires local allocation of kidneys from cadaveric donors >= 65 years to recipients >= 65 years.Methods. Of all patients :65 years who received a kidney transplant in 1999-2002 at our center, 59 patients were transplanted through the ESP protocol (ESP group), and 44 patients received a transplant from a younger donor (EuroTransplant Kidney Allocation System, ETKAS group). Recipients were followed for up to 5.3 years using the Austrian Dialysis and Transplant Registry. Outcomes studied included all-cause mortality and allograft loss.Results. Age, sex, and comorbid conditions did not differ by group. Donor age was higher (69 vs. 36 years; P < 0.001) and cold ischemia time shorter in the ESP group (10 vs. 15 hr; P < 0.001). Number of HLA mismatches was greater in the ESP group (3.8 vs. 3.0; P = 0.003). ESP patients were more likely to receive induction therapy and less likely to receive cyclosporine A. Primary nonfunction, delayed graft function, operative mortality, rate of acute rejection episodes, and length of stay did not differ by group. Although serum creatinine at discharge was higher in ESP patients (1.7 vs. 1.4 mg/dL; P < 0.001), 4-year mortality (hazard ratio [HR] = 0.68; 95% Cl: 0.31-1.49) and graft loss (HR = 0.61; 95% CI: 0.29-1.28) tended to be less.Conclusions. Long-term patient and graft survival were comparable between elderly patients who received their organ via the ESP and the regular ETKAS algorithm.

An increasing gap between supply and demand of donor kidneys for transplantation exists. There is concern regarding the allocation of scarce organs to elderly patients, because the benefit obtained by the transplant may be less in elderly compared with younger recipients. It was the objective of this study to determine differences in patient and organ survival between organ recipients >65 yr and 50 to 64 yr of age at transplantation. A retrospective cohort of 627 patients >50 yr who received a kidney transplant between 1993 and 2000 was assembled. Detailed information on patient demographics, comorbidities, and immunological and donor characteristics was ascertained before transplantation. Five-year patient and graft survival were evaluated by Kaplan-Meier survival curves and multivariate Cox proportional-hazard models. Five-year patient mortality was similar between patients aged >65 and 60 to 64 at transplantation (relative risk [RR] = 1.07; 95% confidence interval [CI], 0.66 to 1.74). Patients aged 50 to 59 yr showed a clear trend toward lower 5-yr mortality (RR = 0.66; 95% CI, 0.43 to 1.03). Compared with patients >65 yr, 5-yr graft loss was not different in patients aged 60 to 64 (RR = 1.28; 95% CI, 0.82 to 2.02) or those aged 50 to 59 yr at transplantation (RR = 1.02; 95% CI, 0.68 to 1.53). After thorough control for confounding, 5-yr graft survival was not materially different by age group. Discrimination against older candidates for kidney transplantation on age-related grounds alone is not warranted.

As the number of elderly patients suffering from end-stage renal disease has increased almost threefold during the past 20 years all over the world, new strategies for the treatment of such patients have been developed. Better screening has made renal transplantation a valuable resource in elderly end-stage renal disease patients. Improved immunosuppressive protocols as well as the expansion of the donor pool by using older and living donors for older recipients have improved patient survival rates as well as the quality of life in this patient population.

Fabrizii, Veronika1; Mittermayer, Christoph2; Muellner, Marcus3; Woisetschlaeger, Christian3; Kaiser, Alexandra1; Steininger, Rudolf2; Muehlbacher, Ferdinand2; Hoerl, Walter H.1; Druml, Wilfred Author Information

Fabrizii, Veronika1; Kaiser, Alexandra1; Mittermayer, Christoph2; Muellner, Marcus3; Woisetschlaeger, Christian3; Steiniger, Rudolf2; Muehlbacher, Ferdinand2; Hoerl, Walter H.1; Pohanka, Erich1 Author Information

Time of blood sampling 0 120 Introduction (min after IAS start) Respiratory rate (min−1) 12 10 After having lost his first renal allograft early after Haematocrit (%) 23 31 pH 7.44 7.19 transplantation because of irreversible acute vascular 2 (mmHg) 43 80 rejection, a 57-year-old man received his second graft HCO−3 (mmol/l ) 24 32 at our institution in August 1997. In the meantime he SBC (mmol/l ) 25 27 had been on maintenance haemodialysis at a local 2 (mmHg) 59 108 community hospital three times a week using his 2 (%) 94 96 Cimino–Brescia fistula on the left forearm without any severe medical problems. Based on the medical history and the high percentage of panel reactive antibodies The patient’s body-weight was 6 kg higher than his (66%) prior to transplantation, he was put on quadusual dry weight on dialysis; however, he was in a ruple immunosuppressive therapy using cyclosporin good general condition. Blood gas analysis using blood A, mycophenolate mofetil, steroids, and ATG. from the arterial line was done on a routine basis Immediately after engraftment the transplanted kidney before treatment was started and revealed normal started urine production and within 5 days the serum values except for a moderate hypoxaemia and renal creatinine reached normal values. Because of an anaemia (see Table 1). He was also feeling well when increase in serum creatinine on day 9 an allograft after 2 h of immunadsorption therapy a second routine biopsy was performed which revealed grade II rejection gas check was performed, which revealed a surprising according to the Banff classification and as an addiresult (Table 1). tional immunosuppressive device plasma immunoadsorption therapy using staphylococcal protein A covered columns was started. His Cimino–Brescia What is your explanation? fistula was used as vascular access at a flow rate of 70 ml/min. At this time the patient was oligoanuric. (Answer on the next page)

In severe gram-negative infections aminoglycosides generally remain the first-line antibiotic. Their use is limited by the high risk of side effects and, especially, nephrotoxicity. High peak levels are crucial for antibacterial activity, whereas toxic side effects are deter mined by the more prolonged trough levels. Thus, aminoglycosides should not be given by intramuscular injection because the peak levels achieved are inadequate whilst long-lasting elevated plasma trough levels result. On administration of a daily single dose intravenously high antibacterial efficacy can be combined with low nephrotoxicity. Besides the dose-dependent bactericidal effect, the postantibiotic effect of aminoglycosides is of importance.The main site of nephrotoxicity are the proximal tubule epithelial cells. Renal toxicity is usually reversible after discontinuation of drug therapy. Toxic acute renal failure is not uncommon (5-35%) and usually dependent on the underlying disease, preexisting renal function, hydration state, age, cumulative dose, additional medication, previous therapy with aminoglycosides and the choice of the specific aminoglycoside. By implementing a single daily dose regimen in conjunction with adequate hydration, alkalization therapy with bicarbonate, monitoring of plasma trough levels and minimization of the duration of therapy (5 days), development of renal impairment can be prevented in the large majority of patients. Hence, acute renal failure has become an avoidable, and much less frequently observed complication of aminoglycoside therapy due to these measures.

We report a right-sided tonsillar carcinoma in a 33-year-old renal graft recipient on cyclosporine A plus low dose prednisolone treatment. The patient had been a life-long non-smoker and alcohol abstainer. The undifferentiated rapidly growing tumour became manifest in the fifth year after transplantation. The clue to the early recognition of this aggressive tumour (T2N0M0G3) resulting in a hitherto favourable outcome after excision and irradiation above all lied in the alertness of the patient himself.

IL-1 activity is increased in hemodialysis patients and interest has recently been focused on IL-1 antagonism in various clinical settings. We studied the presence of anti-IL-1 alpha autoantibodies in sera from 49 hemodialysis patients, 159 kidney graft recipients and 89 chronic renal failure patients without renal replacement therapy. Within the three month study period 32.6% of the hemodialysis patients were found to present with anti-IL-1 alpha autoantibodies, in contrast to 5.6% of kidney graft recipients, 8.9% of chronic renal failure patients, and only 1.4% of healthy subjects. The presence of these autoantibodies was neither associated with primary kidney disease nor with the type of dialysis membrane we used. In addition, in antibody positive patients a pronounced increase of IL-1 alpha serum levels within a dialysis session from 14.8 +/- 4.7 pg/ml to 26.4 +/- 11.2 pg/ml (P less than 0.0005) was observed, contrasting to the more even increase from 14.1 +/- 3.1 pg/ml to 19.3 +/- 12.7 pg/ml (P less than 0.05) in the antibody negative group. Neither clinical symptoms due to adverse effects of IL-1 alpha nor some influence on erythropoiesis mediated by IL-1 alpha could be envisaged. Thus, we believe, that anti-IL-1 alpha autoantibodies, present in high frequency in hemodialysis patients, have a neutralizing effect on IL-1 alpha in these patients.

beta-N-acetylglucosaminidase (beta-NAG) and beta 2-microglobulin were assessed in two cohorts of patients with glomerular or tubulointerstitial diseases respectively. While beta-NAG activities did not differ statistically significantly between both groups, beta 2-microglobulin excretion was statistically highly significantly increased in the setting of tubulointerstitial diseases. On the whole mean beta-NAG activity at 37 degrees C and beta 2-microglobulin urinary excretion were elevated in both groups, when compared to normal controls. Increased beta-NAG activities above 10 U/g creatinine were associated with a marked increase of creatinine serum levels within 6 months in both, patients with glomerular and tubulointerstitial basic renal diseases. beta-NAG and beta 2-microglobulin are useful tools in diagnosis and assessment of renal diseases elucidating different aspects.

S OF THE XVlll th ESAO CONGRESS VIENNA, 11-14 September 1991 COMPARISON OF PLASMASEPARATION AND IMMUNOSPECIFIC LDL-ELIMINATION IN SEVERE HYPERCHOLESTEROLEMIA. K.Derf1er, K. Widhalm *, K.Swoboda, M.M.Hirschl, M. Gottsauner-Wo1f **, V.Fabrizii, G.Steger, A.C. Hauser., G. Sunder-Plassmann,P.Balcke. I.Med-, Dept., Div. of Nephrology; *) Clinic for Pediatrics; **) Clinic for Cardiology; Univ. of Vienna; AUSTRIA. The genetic defect of the receptormediated cell uler uptake of LDL is associated with excessive plasma total and LDL cholesterol [C]leading to increased risk of early myocardial infarction [MIl. Failure of medical treatment in these patients enforces extracorpora1 therapeutical intervention. Though apheresis was not available, we performed plasma separation [n= 14, exchange of 3000ml/session] in 3 patients [2 with homozygous type; age 16yrsl no history of MI; 25yrs I MI at the age of 14yrs, 1 heterozygous type; age 56 yrs/previous MI).Following this,immunospecific LDL-apheresis was started [n=30] using Apo-B containing columns (Baxter, Munich,FRG). Effectivity I side effects in both form's of treatment are compared. # ma/d1 ; *) p< 0.001; p< 0.005 PLASMASEPAR. LDL-APHERESIS Tota1-C # 463±73 I 188±53 * 443±83/216±88* LDL-C # 408±90 I 155±55 * 391±671143±49* HDL-C # 29±2.8 I 16±4.9 * 34± 81 29± 6 * IgG # 1360± 143/491 ± 107* 1358± 192/11 09± 157* IgA # 508± 188 I 154± 57* 441 ± 135 I 350±99* IgM # 129± 50 I 38± 11 * .. 123±48 I 102±47* Side effects (hypotension, headache,..) were only observed frequently during plasma-separation. Comparison of both treatment modes LDL-apheresis was associated with serious beneficial effects especially on immunoglobulins and HDL-cholestero1 metabolism. 209 210 CELLULAR REACTIONS TO IMPLANTED FIBROUS CARBON ADSORBENTS (ACFM)AS INDICATOR OF THEIR BIOLOGIOAL OOMPATIBILITY E.v.Eretsk~a, B.J.Goldsohmidt, O.V.Yurohe 0 The Institute for Onoology & Radiobiology Problems, Ukr. Aoad. of Soi., Kiev, USSR. We performed a oomparative morphologioal study of the nature of the development of oellular arohiteoture in the ~anular tissue as a response to implantat~on into soft tissues of rats, of gauze, daorone, AOFM. Administration of foreing matter results in the development of ohronio granulomatous inflammation with formation of mature maorophageal granulomas. Granulomatous inflammation has oertain struotural oellular peouliarities following implantation of different sUbstanoes, whioh is oharaoterized by marked lymphoid, histiooytio, epitheliooellular, maorophageal, fibroblastio proliferation, a predominanoe of oertain oellular forms and expression of oonneotive tissue development. Light and eleotronio miorosoopy revealed polymorphous oomposition of granular tissue with lymphooytes, maorophages, fibroblasts, fibrooytes with development of intercellular lymphooyte-maorohageal and lymphooyte-fibroblastio oontaots, whioh oan refleot an adequately expressed biologioal oompatibili ty of the AOFM to tissues. CHANGES IN HEMORHEOLOGICAL PARAMETERS BY EXTRACORPORAL LDL-IMMUNOABSORPTION. R. Koppensteiner, K.Derfler, K.Swoboda, M.GottsaunerW01f*, M.M.Hirsch1, G.Steger, P..Ba1cke.I.Med. Dept, Div. of Angiology; *) Gardiolog. Dept; Univ. Vienna, AUSTRIA. EXTRACORPORAL IMMUNOSPECIFIC LDL-CHOLESTEROL ELIMINATION IN HOMOZYGOUS AND HETEROZYGOUS HYPERLIPOPROTEINEMIA. A NEW THERAPEUTIC APPROACH FOR DIALYSIS UNITS. K.Swoboda, K. Derfler, V.Fabrizii, G.Sunder-Plassmann, G. Steger, M.Gottsauner-Wolf *, K.Wjdhalm **, P.Ba1cke. ' I.Med.Dept, Div. of Nephrology; *) Dept. of Cardiology; **) C1in. for Pediatrics; Univ. of Vienna; AUSTRIA. Elimination of apolipoprotein B (Ape-B) containing plasma lipoproteins using extracorporal imm unospecific ApoB antibodys recently has been reported to be highly effective in lowering LDL-cholesterol lcnoll in homozygous (Type I) and severe forms of heterozygous (Type II) hypercholesterolemia both groups highly concerned by coronary artery disease (CAD). We report our first experience in 2 male type I patients (age: 16 yrs I without CAD; 25 yrs I previous myocardial infarction [MI] at the age of 14 vr s) and 2 type II patients ( 1 female I age 52 yrs; 1 male 56 yrs; both with a history of MI). During 5 month 37 treatments were performed (9/10/11 and 7 treatments in the individual patient). Plasma was separated using a conventional plasma-filter. Desorption of LDL was done by a pair of antibody-carrying columns (Baxter, Munich, FRG). Anticoagulation was achieved by heparin (bolus 4000 U; 2000 U I hour). BEFORE AFTER I APHERESIS P Total cholesterolv 451±83 216± 86 .0001 LDL-chol. # 393±67 l43± 49 .0001 HDL-chol. # 34± 10 29± 7 .0005 Apo-B # 173±3l 98±34 .005 Triglycerides # 601 ± 1145 309±617 .005 # mg/dl No severe side effects were notedover the entire study period, Beside drastically lowering of Apo-B delipidating of xanthomas was observed i~ both type I patients. 212 211 p <0.06 < After 228±61 1.57±0.1 The main target of LDL-apheresis is the reduction of LDL-cho1esterol. In spite of the known high prevalence of coronary heart disease in these patients, special interest has been drawn on changes in microcirculation. We there-fore investigated the effect of LDL-apheresis on several important rheological parameters in 2 patients with homo-zygous (age: tsvrs, 25 yrs I previous myocardial infarc-tion (MI) at the age of 14 vrs) and 2 patients with severe heterozygous (age: 56yrs; 52yrs; both with a history of MI) familial hypercholesterolemia. 12 measurements, each before and following treatment were performed during a treatment period of 5 month.Mean LDL-values before treatment were 391 mg/dl and after apheresis 143 mg/dl. Before 286±81 1.78±0. 1 Fibrinogen (mg/d]) Plasma viscosity (mPa.s) 0.009 Ery aggregation I stasis * 7.69±2.0 5.54± 1.6 <0.009 Ery aggreg. at low shear * 11.0±2.9 7.80±2,4 <0.009 ( 3/sec) Thrombocyte aggreg. (::t;) 64.7± 14 58.5± 14 N.S. Hematocrit (::t;) 37.5±4.0 37.7±4.0 N.S. *) = Arbitrary Units Our results demonstrate a significant improve in hemorheologic parameters by LDL-epnerests, 588 © by Wichtig Editore, 1991 The International Jour~al of Artificial Organs / Vol. 14/ no. 9, 1991 ABSTRACTS OF THE XVlll ESAO CONGRESS VIENNA, 11-14 September 1991S OF THE XVlll ESAO CONGRESS VIENNA, 11-14 September 1991 l'LASr,IAPHEHESIS AND I'LAS1VIASORPTION IN CHITICAL STATES. Dh.Z.Easimov, I.I.Kornienko. Tashkent branch of the National Research Centre of Surgery,Tashkent,USSR. Application of the contemporary methods .or gravity surgery and sorption technology for toxic substances elimination provided economic and social benefit. Our assesment of the efficacy of these procedures based on results of 73 plasmapheresis(PP) and plasmasorption(PS) in patients with liver cirrhosis,pancreatitis and peritonitis. Investigations revealed, that PP and PS reduced level of bilirubin on 35%, enzymes on 47%,Hystamine on 37%, serotonin on 42%, bile acids on 70%, oligopeptides on 55% in patients with severe endogenous intoxication and multiple organ failure in a short time. l'lasma loss was compensated with plasmaperfusion through charcoal sorbents SKN series,so the plastic substances were reinfused into organism. Long application of PP and PS may be accompanied with temporary anemia, ~ypocoagulation and reducing of blood velocity. nut these detoxification methods' efficacy exceed its' danger for possible complications. JmS rrn; 'I'm1~ IMPARE 'lHE RkNAL FmJ'IOO ? Srinichi Ihscl.ere exanined in eighteen patients (7 patients with myast:renia gravis, 5 patients with nultiple sclerosis, 4 patients with chrmie inflamratory demyelinating polyradicalmeuropathy, 2 patients with reheumtoid arrythritis). IilN, serun creatinine levels, urinalysis, protein in urine and <:1.1-microglobulin values in urine were neasured pre and post every PP therapy. Also , electrolytes in serun such as Na, K, Cl, Ca and Pi. \Ere exanined pre and post PP for o.u years. These examinatims >.ere performed for o.u years in those 18 patients. 18 patients received every tvo weeks PP therapy and total 48 tiIres of PP in two years. IilN levels >.ere lQ!:4 ng/dl, before the start of PP and 1l±5 ng/dl after tvo years; (the end of total 48 tiIres PP). There were not statistical significant difference. No significant difference of semn creatinine levels betl;een 0.7:10.2 rrg/dl before the start of PP and 0.6:10.3 ng/dl, at the end of total 48 tiIres PP therapy, (after 2 years). In urinalysis, red blood cell, Ioffite blood cell, and cast \Ere not found each pre and post PP for o.u years. Protein and sugar in urine .ere not foond during PP for two years.D(j-microglobulin values in urine were norrral, each pre and post PP for two years and the difference of oIt-mierog1obulin levels betseen start of PP therapy and at the end of 48 tines PP (after o.u years) were not found, The values of electrolytes in semn did not significantly change with PP treatment after two years. These results indicated that PP therapy did not irnpared renal functim. In eonc1usim, PP treatment did not danBge to the renal functioo. © by Wichtig Editore, 1991 213