Thoracic Duct Fistula and Renal Transplantation

Abstract

Thoracic duct drainage (TOO) was established for 21-115 days in 40 kidney recipients with an average removal per patient day of 4.7 I lymph and 1.88 billion cells. Cellular and humoral immunity were depressed. TOO and immunosuppressive drugs were started at transplantation in 35 recipients of cross-match negative grafts. Althougb the results were better than in precedent non-TOO controls, eight patients rejccted their ~~rafts before a full TOO effect, and three of the eight developed predominantly anti-B lymphocyte cytotoxic antibodies which were probably responsible for positive cross-matches with their next donors. With continuing TOO, all eight patients had good initial function after early retransplantation. In five more "non transplantable" patients with performed cytotoxic antibodies, TOO was started 30-56 days before transplantation. In these five pretreated patients, antibodies persisted with positive antidonor cross-matches. Hyperacute rejection occurred repeatedly in two patients with high anti-T (and anti-B) titers, but was surmounted in three patients with lower titers. From the clinical and immunologic data, we have concluded that TOO should be used for pretreatment of all cases with or without prior antibodies, and have suggested an adjustable management plan that takes into account new developments in antibody monitoring.T HE IMPERFECTIONS of immunosuppression for renal transplantation are well known, particularly when cadaveric donors are used. 46 Treatment often does not control rejection on the one hand, or is excessively dangerous on the other. The consequence is that renal transplantation has not lived up fully to the optimistic expectations of a decade or longer ago, a fact that increasingly has clouded the proper relationship between transplantation and its alternative. dialysis.

Human Leukocyte Subpopulations from Inflamed Gut Bind to Joint Vasculature Using Distinct Sets of Adhesion Molecules

“…Although these leukocytes are thought to be mostly sessile cells, there is evidence that tissue macrophages can leave the stroma by reverse transmigration and are indeed found in efferent lymph (34,35). Therefore, these cells can be envisioned to play an important role in carrying mucosal Ags into distant tissues such as synovium.…”

Successful liver allografts in mice by combination with allogeneic bone marrow transplantation.

“…Since then, more than 500 patients have been treated with this method (2,3). In all species, liver allografts are rejected less aggressively than allografts of other organs (4-6), probably because Ia antigens are less prominent on liver cells than on cells of other organs.…”

Effect of Preoperative Thoracic Duct Drainage on Canine Kidney Transplantation

“…Kidney graft survival was not significantly altered by 3 weeks of TDD but was doubled after 6 and 9 weeks. As in humans [19][20][21], this timing of therapeutic effect was out of phase with the T-Iymphocyte count, which was depressed almost immediately after TDD and remained low thereafter.…”

“…In Gowans' original rat experiments [7] and with long-term external TDD in humans [18][19][20][21], humoral and cellular immunity were both depressed. This duality was controversial at the time of the human trials because at that time a pure cell-mediated effect was expected or reported by some investigators.…”

“…Much later, it was shown in patients with autoimmune diseases [18] and in transplant recipients [19][20][21] that immunosuppression was not demonstrable until after 3 to 4 weeks of TDD instead of the 5 days in rats. Studies in large animal were hampered, as they were in humans, by the difficulty of maintaining long-term external TDD.…”