RENAL-ALLOGRAFT RUPTURE - A CLINICAL REVIEW

Rupture of a renal allograft (RAR) is an uncommon but serious complica tion of renal transplantation. A recent RAR prompted a review of our e xperience, with the purpose of (1) identifying conditions that may pre dispose this complication and (2) defining strategies for prevention. A 5-yr, consecutive living-related (LRD) and cadaver donor (CD) cohort of 331 patients was studied retrospectively. Twelve patients (3.6%) h ad RAR. Donor characteristics, procurement and preservation conditions , and recipient characteristics were major study categories. Data anal ysis was computer-based and included multivariate analysis. The nine W hite and two Black cadaver donors were ''ideal'', mean age 29 yr, with mean high creatinine (CR) of 1.3 and terminal CR of 1.1 mg/dl, and me an terminal urine output of 423 ml/min. Nine of 11 CD had low-dose dop amine use (terminal, mean 8, range 5-13 mu g/kg/min). Eleven of 11 don ors had procurement en-bloc, 9 of which were multiple organ procuremen t. All had 4+/4+ flush and cold storage with UW solution. Mean cold is chemia time (CIT) was 22 h, 28 min (range 15 h, 16 min to 40 h). For p atients with RAR mean age was 39 yr; there were 12 Black patients and 7 males, 5 females. HLA match was 1 antigen (AG) for 3, 2 AG for 8, an d 4 AG for 1 (mean 1.9). Nine patients had delayed or declining renal function requiring dialysis. The panel reactive antibody was at peak, mean 47% (range 0-100%) and current, mean 18% (range 0-84%). Six of 12 had OKT3 therapy at time of RAR and six had biopsies. Day of RAR was mean 10, median 9 (range 4-21). Pain and drop in hematocrit were obser ved in most. There was one fatality (8%), and all kidneys were removed . All kidneys showed at least minimal rejection but six had severe acu te tubular necrosis (ATN) with edema and minimal rejection. Statistica lly significant associations with RAR were older recipient age (p=0.04 ), donor-recipient race mismatch (White donor to Black recipient) (p=0 .007), and dialysis requirement (p<0.0001). Other variables were not s tatistically correlated: gender, race, CIT, transplant number, LRD vs. CD, peak or current PRA, and total HLA and BDR mismatch. The data sug gest that ATN and rejection act synergistically to cause RAR and that early delayed function requires intensive and perhaps novel immunosupp ression, especially in Black recipients.