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(1997). STAFFING AND TRAINING THE SA ARMY OF THE FUTURE. African Security Review: Vol. 6, No. 3, pp. 58-65.

Approximately one sixth of patients receiving renal transplants have a functioning kidney beyond 20 years. Chronic rejection is the predominant cause of late allograft loss. Malignancy, cardiovascular disease, hepatic failure, and infections are the major causes of late death. Early detection and control of the risk factors that contribute to patient death should favorably influence the long-term success of renal transplantation.

In August 1992, we replaced Minnesota antilymphocyte globulin (MALG) with lymphocyte immune globulin, antithymocyte globulin (equine) (ATGAM) in our immunosuppression protocols. The clinical impression of increased graft rejection prompted our assessment of the effect of this change on patient and graft outcome. The initial study group consisted of 426 renal transplant recipients transplanted between October 1, 1987, and September 21, 1993. After exclusions, 388 transplant events, with a minimum 8-month follow-up, made up the final study cohort: 323 patients received MALG and 65 received ATGAM. Immunosuppression included intravenous methylprednisolone, oral prednisone, oral AZA, CsA in some cases, and intravenous MALG or ATGAM, 15 mg/kg/day, for 7 to 14 days. Acute rejection was treated with high dose intravenous steroids and steroid-resistant episodes were treated additionally with either MALG or OKT3. Statistical comparisons were stratified for multiple patient characteristics and treatment variations. There was a greater incidence of rejection in general, and a higher incidence of steroid-resistant episodes requiring subsequent antilymphocyte globulin therapy (P = 0.0073) in patients receiving ATGAM versus MALG. No difference was seen in the incidence of CMV infection or blood-borne sepsis. Lymphoma occurred in 3 MALG and 2 ATGAM recipients. MALG recipients were significantly less likely to experience rejection within the first 60 days after transplant (P = 0.0127 using unstratified data; P0.0001 when data were stratified for patient characteristics). The relative risk of acute rejection for posttransplant days 5, 7, 10, and 14 was consistently higher for ATGAM-treated patients. We conclude that MALG and ATGAM are not equivalent drugs, and that MALG is a more effective immunosuppressant, and is just as safe as ATGAM in our protocol environment.

Dialysis-associated steal syndrome (DASS) occurring after creation of arteriovenous fistulas often necessitates ligation of the fistula. From June 1987 to June 1990, a total of 542 upper extremity arteriovenous fistulas were constructed: radiocephalic fistulas in 182 patients, 325 forearm loop grafts and 32 upper arm loop grafts. We managed 27 patients with DASS including two patients who were referred from other hospitals. DASS developed in two patients (1%) with radiocephalic fistulas and in 23 patients (6.4%) with arteriovenous grafts. Of the 27 patients, the fistula was ligated in nine because of tissue loss, severity of symptoms, or absence of improvement in digital pressure with the fistula occluded. Intraoperative digital photoplethysmography was used to guide the amount of graft narrowing in 16 patients. The goal was to obtain a digital blood pressure of 50 mm Hg or digital to brachial ratio of more than 0.6. Ten of the 16 patients had satisfactory graft function for more than 6 months, and all patients had improvement or resolution of the steal syndrome. We conclude that DASS is an uncommon complication of upper extremity arteriovenous shunts and narrowing of the fistula and that using intraoperative digital photoplethysmography as a guide is a useful method for relieving the steal syndrome and salvaging the shunt.

Approximately one-third of the patients receiving renal transplants have functioning allografts at 10 years. Chronic rejection continues to be the leading cause of kidney loss in late survivors. Atherosclerotic cardiovascular disease, liver failure, malignancy, and sepsis are the major causes of late death. Identification and control of the risk factors contributing to patient mortality should enhance the long-term success of renal transplantation.

Thirty-four patients with acute gastroduodenal hemorrhage were treated with intravenous Cimetidine. Preliminary endoscopy was done at the onset of bleeding to determine the source of bleeding and to rule out the presence of a brisk arterial bleeding site that would require immediate operation for control. Sixteen of the patients had primary peptic ulcer disease and 18 patients had "stress ulcer" syndrome. The bleeding stopped following Cimetidine administration in 14 of the 16 peptic ulcer patients (88%) and in 13 of 18 stress ulcer patients (72%). There was no subsequent rebleeding. The data suggest that Cimetidine is of value in the immediate nonoperative management of acute gastroduodenal hemorrhage. Further, the availability of Cimetidine for postoperative use may modify the surgical approach to stress ulcer bleeding.

In this study, we analyzed the incidence of complications and clinical results of 57 patients who received kidney transplants at our institution and survived with a functioning allograft for 10 years or longer. All patients received their care at our center and their clinical and laboratory data were monitored routinely at minimum monthly intervals. In this second decade, during a mean follow-up of 2.8 +/- 2.2 years (range 0.4-7.8 years), 7 patients suffered graft loss (chronic rejection 6; irreversible acute tubular necrosis from aminoglycosides 1) and 7 others died with a functioning allograft (causes: hepatic failure 2, sepsis 2, malignancy 2, and cardiac infarction 1). The cumulative patient survival was 96% at 11 years and 85% at 15 years. The corresponding graft survival rate was 92% at 11 years and 71% at 15 years. Of the 43 patients currently followed, 38 are fully rehabilitated, 4 are partially rehabilitated, and 1 is medically disabled. The complications observed were: infection in 25 patients (44%), hypertension in 24 (42%), hyperlipidemia in 23 (40%), liver disease, 22 (39%) musculoskeletal problems in 21 (37%), cataracts in 19 (33%), rejection in 15 (26%), malignancy in 9 (16%), vascular occlusive disease in 9 (16%), gastrointestinal disorders in 9 (16%), and other problems not included in the above categories in 26 (46%). Our observations suggest that renal transplant recipients experience significant morbidity and mortality even in the second decade. Continued medical follow-up is therefore essential for an early diagnosis and management of these late complications. Measures directed at prevention and therapy of these late complications may further enhance the long-term success rate of renal transplantation.

A middle-aged man with idiopathic membranous nephropathy, who developed chronic renal failure, received a cadaver renal allograft. Two months later, massive, persistent proteinuria developed. A biopsy specimen of the allograft showed changes characteristic of membranous nephropathy and identical to those present in the patient's own kidney. The criteria for recurrence of glomerulonephritis in renal allografts are met in this case.

Renal hyperparathyroidism can be a major clinical problem in those receiving dialysis treatment and in those having renal transplants. This review of 66 patients during a five year period has led us to believe that laboratory data are useful for confirming the clinical diagnosis or for following the outcome of medical or surgical therapy. The screening for renal hyperparathyroidism should be on clinical grounds and not on isolated biochemical tests. All patients with renal failure, whether receiving dialysis therapy or renal transplantation, are at risk for having renal hyperparathyroidism develop. A careful assessment of the clinical and biochemical data is required to ensure proper patient selection for operation. Bone disease and persistent pruritus unresponsive to medical management remain the principle clinical indications for operation. Our preferred procedure is the standard subtotal parathyroidectomy.