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Unlabelled: The importance of certain positive crossmatches (CM+) in kidney transplantation remains controversial. Fifty consecutive kidney transplants were performed across a CM+ between Jan. 1990-April 1994. In 19 cases there was an isolated B-cell CM+ (Group I), in 24 an historic T-cell IgM CM+ (Group II) and in 7 an historic T-cell IgG CM+ (Group III). Comparing groups I:II:III: early acute rejection affected 32%, 42%, 57% of grafts; mean serum creatinine at 3 months was 166, 150, 229 umol/l (p < 0.05); 1 yr graft survival was 95 per cent, 96 per cent, 71 per cent (p = 0.09). In group III both graft losses were in the setting of an additional current B-cell CM+., Conclusions: Transplantation performed in either the presence of an isolated B-cell CM+ or in the presence of an historic T-cell IgM CM+ was associated with acceptable outcomes at 1 yr. An historic T-cell IgG CM+ was confirmed as a contraindication to transplantation in most circumstances, especially when coupled with a current B-cell CM+.

Severe hypothermia is associated with serious patient morbidity and mortality. The groups most frequently affected are the elderly, the very young and substance abusers. We describe three such cases which were successfully treated using warmed peritoneal dialysis. Two patients recovered completely and were left with no long term deficits. The third patient recovered from the acute event, but succumbed later to an underlying medical condition. Warmed peritoneal lavage is an efficient, cost effective approach which is easily performed without specialist equipment, and involves minimal risk to the patient.

The number of renal transplants has been increasing steadily over the last twenty years. This increase has been associated with a significant improvement in the one year graft and patient survival. However, as survival improves, long term complications are becoming more clinically important. We, therefore, retrospectively reviewed our experience of renal transplantation in 165 patients between January 1970 and December 1980, and describe in detail the complications experienced by those whose grafts functioned for 10 years or longer. The 10 year patient survival rate was 47% and graft survival rate was 30%. The graft survival rate for living related grafts was superior to that of cadaveric grafts. The major cause of mortality in the first year following renal transplantation was infection and in subsequent years, cardiovascular disease predominated. Patients whose grafts functioned for 10 years or more developed a variety of complications including infection, skin cancer and hepatic dysfunction. Clinicians involved in the long term care of the patients need to be aware of these problems and skilled in their management.

It is well recognised that haemodialysis and renal transplant patients are at increased risk of developing non-A, non-B hepatitis. Recently the genome of hepatitis C virus (HCV), the major causative agent for non-A, non-B hepatitis, has been isolated. Anti-HCV seroprevalence was assessed in all haemodialysis patients (266) in Ireland who in March 1990 had been dialysed for at least 6 months. For comparative purposes, 272 patients who had functioning renal transplants for greater than 6 months were also studied. Potential risk factors such as age, number of blood transfusions and time on dialysis were evaluated. The prevalence of HCV infection as evidenced by antibody detection was only 1.1% for transplant and 1.7% for haemodialysis patients. This compares to a reported incidence of between 10% and 50% found elsewhere. Two of the 5 anti-HCV positive haemodialysis patients and 2 of the 3 transplant patients had biochemical evidence of liver disease. From stored sera it was possible to ascertain when patients acquired HCV. Whether the very low prevalence of anti-HCV in Irish patients is due to the low prevalence of the virus in the general population, the policy of non reimbursement of blood donors, genetic or other factors, remains to be determined.

We treated 57 patients who suffered from end stage renal disease (ESRD) with recombinant human erythropoietin (EPO) for a mean period of 56 weeks. Patients were aged between 18 and 81 years. Forty three patients were on haemodialysis and 14 on continuous ambulatory peritoneal dialysis (CAPD). Despite regular transfusions, the mean haemoglobin prior to EPO therapy was 7.4 g/dl +/- 1.7. The target haemoglobin of 10 g/dl was reached at a mean of 12 weeks for the CAPD patients and at 14 weeks for the haemodialysis population. Patients were noted during the study to have a progressive rise in mean red cell volume, and this appeared to be related to their level of iron stores. The mean dose EPO used to reach the target haemoglobin was 8,700 u/week (125 u/kg/week) for the haemodialysis patients and 7,200 u/week (102 u/kg/week) for the CAPD patients. Three patients (7%) developed thrombosis of their A/V fistula. Hypertension was exacerbated in 28% of the patients. We conclude that EPO is a very effective but not inexpensive therapy for the anaemia of ESRD.

We compared the incidence of clinical CMV illness in 25 renal transplant recipients treated with OKT3 for steroid resistant cellular rejection with 88 renal transplant patients treated only with conventional immunosuppression (cyclosporin A and steroids). Nine (36%) patients in the OKT3 group developed CMV illness compared to (2.3%) amongst those treated conventionally (p < 0.0005). Patients who received OKT3 were divided into four groups according to the CMV antibody status of the donor and recipient. Six of the 9 episodes of CMV infection occurred in patients not previously exposed to CMV, who received a kidney from a CMV positive donor. Three (12%) of the patients treated with OKT3 died of CMV disease. A further 2 patients died of other causes giving an overall mortality in the OKT3 treated group of 20%. We concluded that when OKT3 therapy is used in association with donor/recipient CMV mismatch it is associated with a high CMV morbidity and mortality.

Between 1980 and 1990, 862 renal transplants were performed at our unit. Forty-six of these were given to 38 children. The mean age of the children was 8.6 years. Reflux nephropathy accounted for 39% of the primary renal diseases, followed by congenital disorders (30%), and glomerulonephritis (16%). Seventy percent of the grafts were from cadaveric donors. The one year patient survival was 90%, and the one year graft survival 61%. Seven children received a second graft with a one year graft survival of 71%.

One hundred and forty-nine renal transplant patients attending 2 centres in Dublin were examined. Twelve patients (8.1%) were found to have cutaneous malignancy while dysplastic lesions (premalignant and/or malignant) were identified in 34 (22.8%). The prevalence of cutaneous malignancy in this study is substantially greater than that of previous Irish studies. The introduction of cyclosporin A (CyA) as a new and more effective immunosuppressive agent in renal transplantation may in part explain this increase.

Nine adult patients with resistant nephrotic syndrome were treated with cyclosporin A (CyA). All had failed to respond to high dose corticosteroids with or without cyclophosphamide. Three patients had minimal change disease, 3 had focal sclerosing glomerulosclerosis (FSGS), 2 had mesangiocapillary GN, and one had membranous nephropathy. The mean age of the patients was 26.4 years (range 16 to 39 years). CyA was given orally twice daily at a mean dose of 6.7 mg/kg/24 hours (range 6-10 mg/kg/24 hours). Four patients achieved full remission, two patients went into partial remission and three failed to respond. Two patients developed clinical nephrotoxicity, which reversed on dose reduction or cessation of CyA. All 3 patients with minimal change disease who responded subsequently relapsed after stopping CyA, but remitted rapidly on reintroduction of the drug. We suggest that the mode of action of CyA in nephrotic syndrome may be related to intra-renal vasoconstriction in addition to its direct immunosuppressive effect. In this limited series, we found that CyA can be an effective therapy for otherwise refractory nephrotic syndrome, although relapse on withdrawal of CyA may well be a significant clinical problem.

The clinical and histopathologic findings in 225 Irish adults with nephrotic syndrome were reviewed. Membranous nephropathy was the most common lesion found (28%), followed by proliferative glomerulonephritis (17%), and focal sclerosing glomerulonephritis (16%). Minimal change disease was the least frequent cause for idiopathic nephrotic syndrome (12%). The major secondary cause of nephrotic syndrome was amyloidosis (13%). The patients were analysed for the predictive value of the level of renal function, presence or absence of hypertension, and the degree of proteinuria. It was not possible to determine the nature of the underlying lesion giving rise to the nephrotic syndrome using any of these variables. There was also no significant difference between primary and secondary glomerular disease with regard to these factors. It is concluded that renal biopsy remains the only definitive method of establishing the underlying lesion causing idiopathic nephrotic syndrome.

Twenty five patients with renal vasculitis presenting over an eight year period were reviewed. Ten had microscopic polyarteritis, 6 classic polyarteritis, 5 overlap syndrome, 2 Churg-Strauss syndrome and 2 Wegener's granulomatosis. Clinical features included hypertension, pulmonary involvement, neurological involvement and arthralgia. Serum creatinine was over 500 umol/l in 13 patients, 10 of whom required dialysis. Visceral angiography was positive in 80% of those studied, Focal and segmental necrotising glomerulonephritis was the commonest renal lesion. Treatment consisted of corticosteroids and cytotoxic agents in most cases. Plasmapheresis was used for rapidly progressive renal failure, severe pulmonary haemorrhage or cerebral vasculitis. Improvement or stabilisation of renal function was seen in 68% of patients treated. There were 4 early deaths and one late death. The diagnosis, histology, treatment and outcome of renal vasculitis is discussed. The importance of early diagnosis and treatment is emphasised in this potentially reversible cause of acute renal failure.

Between January 1972 and December 1987, a total of 777 transplants were performed of which 135 (17%) were living related. There were 108 sibling donors, 25 parent to child and 2 child to parent. All sibling transplants were HLA identical. Conventional immunosuppression with Prednisone and Azathioprine was used in all cases. Actuarial patient survival were 95%, 91% and 88% at 1, 5 and 10 years respectively. Corresponding actuarial graft survivals were 90%, 80% and 60%. Graft survival in the sibling compared to the parent to child group was 87% versus 60% at 5 years. There were 13 deaths during the study interval and 32 grafts were lost. Five year patient/graft survivals of 91/80% compare favourably with other reported series. The poorer outcome in parent to child transplants has led us to modify the immunosuppressive protocol to include Cyclosporin A in this group. The increased availability and improved survival of cadaveric grafts in recent years and our one year patient/graft survival of 92/88% has led us to reduce emphasis on living related transplantation in our renal replacement programme.

IgA nephropathy is described in 11 cases out of a total of 177 renal biopsies examined representing an incidence of 6.2 per cent.Reference is made to comparable studies from other centres. Clinical and pathological findings are presented and discussed.

In 20 cases of systemic lupus erythematosus the renal biopsy findings permitted morphological classification with features of prognostic value. Glomerulosclerosis and interstitial fibrosis correlated best with the clinical course. Renal involvement, with a 90% 5 year survival, may have less sinister implications for this population, in contrast with the poor prognosis reported in comparable series.