WEBVTT

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*This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.*

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a United States Army Medical Department Continuing

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education program

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diagnosis of rejection

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with john D.

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Welcome Lieutenant Colonel U.S.

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Air Force Medical Corps Chief transplant

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unit Wilford Hall U.S.

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Air Force Medical Center.

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Lackland Air Force base.

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Despite almost 20 years of experience in renal

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transplantation.

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Now the early diagnoses of graft

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rejection prior to significant insult to the

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graft remains one of the most difficult and

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complex ng problems in clinical transplantation.

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Can we have the first slide please

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from one thinks of rejection.

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He thinks of it in a path a physiological

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consequences.

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These consequences can divided into three areas,

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can be divided into three areas The

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immunological nature of rejection,

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the path of physiological alterations and

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the pathological sequence.

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The ecological nature has been discussed earlier this

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morning and experts in the field will also discuss

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the pathological sequence.

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So we will devote our remarks

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towards the path of physiological alterations.

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These in my mind are extremely important because

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frequently this is the only information the clinician may

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have to make the diagnosis of rejection.

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The path of physiological alterations can be

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classified as chemo,

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dynamic,

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glamorous,

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tabular and urinary

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as stated before.

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A knowledge of this data is very

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important as it is upon this data that the

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physician must depend to make his

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diagnoses very frequently.

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It may be the only data that he has.

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The classification of rejection in general use

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today is divided into

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hyper cute,

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acute and chronic hyper

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acute rejection is a rapidly

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progressive destructive process that

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usually occurs within minutes to hours following the

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transplant today,

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we really have no successful method of dealing with this type of

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rejection.

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Therefore,

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I'm not going to discuss it any further

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is usually not a dubious problem that you're

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dealing with.

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When this occurs,

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acute rejection is a process that

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occurs between days and even

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two up two years.

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Post transplant,

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it has been discussed in some detail today.

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The sailor changes etcetera.

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Since this is a reversible lesion and the one that we

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usually have the most success with this will

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probably this will be the topic of my discussion.

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Chronic rejection is a rather insidious

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process is characterized by slow

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deterioration and final loss of graph graph

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function at the present state of the art.

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We really aren't able to control this and have no successful

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means of treating it over a prolonged period of time.

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The earliest alteration in acute rejection,

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there's a disturbance in the hemo dynamics.

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These changes are present prior to the clinical evidence

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of deterioration in renal function

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and is initially results of the shunning of

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blood away from the cortex to the medulla

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with a corresponding decline in gomorrah and

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tabular function.

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The shunning that we see is probably due to vessel spasm

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and associated a demon that results from immunological

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reaction.

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As the process continues.

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The cortical blood flow further decreases,

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resulting in decreased camera function,

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which results in a decreased sodium delivery to the distal

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tubules.

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T bills is reflected in a loss or decrease of

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sodium excretion as the process

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continues the total blood flow to the graph

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deteriorates in the face of an increasing resistance

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from vessel spasm vessel and

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epithelial swelling micro thrown by an

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increasing interstitial edema resulting from the

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gemological vascular injury and adama.

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Unfortunately,

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these changes lead to further damage,

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creating a rather vicious cycle that will ultimately

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result in death of the graph unless they are altered.

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The decrease in gomorrah filtration and tubular

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function can initially be detected by a decrease in

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heparin clearance.

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This is followed in 24 hours by detectable decrease in the

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creatinine clearance and in 24-48 hours

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by rising serum creatinine.

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This chemical and immunological damage in the

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primarily membrane results in an increased

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permeability of that membrane.

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This is characterized by a loss of excessive amounts

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of protein in the field.

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Trade as a damage to the membrane increases during the

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rejection and ischemic episodes

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larger and larger molecular eight membranes

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become present in the urine.

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A variety of tubular d arrangements in the

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handling of sodium bicarbonate,

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phosphate,

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chloride and hydrogen irons are seen during

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rejection.

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Renal tubular acidosis,

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hyper chlorine,

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mia,

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glucose,

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urea amino acid urea and foss materia may

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occur several days prior to the clinical evidence

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of rejection,

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such as arising Bunn correct name

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due to the ischemic changes in the tubular cells,

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there is a compensatory shift from anaerobic

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too,

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from aerobic to anaerobic metabolism and

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enzymes such as likely D hydrogenated alkaline

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phosphates and listen,

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enzymes may appear in the urine urinary

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firebrand split products and increased numbers

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of Lucas sites,

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neutrophils and red blood cells may also appear

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fever,

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malaise anorexia and a general feeling of poor

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health are frequently associated with the early stages of

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rejection.

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Unfortunately,

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many of these changes also occur in other conditions such as

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infection,

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making the diagnosis somewhat difficult.

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In an attempt to define the criteria that would aid

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us in uh

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recognizing and initiating

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treatment of rejection episodes.

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Early in their course,

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we attempted to establish a

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protocol or at least a list of signs that we could

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depend on.

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To do this.

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We set a criteria major and minor signs.

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In order to make the diagnosis of rejection.

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We have chosen to use two majors.

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One major or one or two miners are four minors as

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the diagnostic criteria in which we would start our immunosuppressive

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protocols.

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The blood studies that we have utilized are those

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probably utilized in most centers,

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although not always consistently

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are standardized,

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are rising creatinine depending upon the

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degree of rise,

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whether whether it be a major and minor sign the same

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for the Buon chloride and the white blood

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cell count.

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The urine studies that we depend upon our

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volume threatening clearance,

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sodium excretion,

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the presence of lymphocyte in the urine and

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protein.

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The physical findings that we have found useful

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are gaining weight,

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swelling of the kidney.

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Our graph characteristics on physical exam,

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hypertension and fever.

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To augment these particular

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criteria.

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We have also utilized serial renal

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scans.

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These scans.

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We first began 24 hours after the transplant

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and then performed the follow up scans every

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2-3 days.

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A typical example of the case of a case

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in which this has been most beneficial was this young

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lady who received a transplant on

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18 September at this

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point in time,

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she had a normal technique,

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easy um flow study which is depicted on this

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slide.

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Her following studies were normal in her clinical

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clinical condition appeared very stable.

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And on 10 October a scan revealed at a

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12-16 2nd flow

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12-16 seconds into a flow study.

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Some deterioration of the flow,

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the technician flow at this

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point in time.

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All of our parameters that we normally measure for

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rejection were normal.

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On the 11th the following day after this scan,

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her her creatinine clearance began to decrease and she

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became febrile On 12

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October.

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Her scan showed further deterioration in the

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flow and uh

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immunosuppressive.

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I mean rejection therapy was instigated

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on 15 October.

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There shows there was a slight improvement in the flow

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and her clinical course

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followed rapidly behind this improvement in scan

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with a dropping of her sim card and an improvement in her

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creatinine clearance and clearing of her fever.

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The hip Iran aspect of the scam.

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We also utilized to determine what is

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happening on the scam.

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This is the hip Iran study.

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This young lady had on the 10th of

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october,

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which unfortunately I do not have the slide for the

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18th showed slight deterioration in her handling

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of hippie ran her up taking clearance

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On 12 October.

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There was even further deterioration again uh

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strengthening our feeling that we were dealing with the rejection on the

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10th and clinically dealing with rejection.

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On the 11th,

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on the 15th of october.

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After four days of him of uh increased doses

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of selenium Pedro,

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she had improvement in her hip here and study the

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following reno grams.

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Further substantiate the findings

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Showing on 18 September a very

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nice renal flow rate,

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a good bladder uh concentration

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On the 10th,

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there was some flattening of the renal flow study with

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some decrease in the accumulation of a die in the bladder

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on the 12th.

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Further deterioration and on the 15th

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some improvement

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thus far in our in our series of patients,

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we have not had to utilize our terry ah graffiti to

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diagnose rejection.

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We have utilized it in certain instances where

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we have experienced acute rejection that is not that does not

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appear to respond to our uh to our

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rejection therapy in an attempt to decide if

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a graft is salvageable or not,

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to get an idea of the radiological changes.

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This is a normal arteriogram that's performed in a young

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man who experienced uh no urine output

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shortly after surgery.

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And uh we felt that he could possibly

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have occlusion of his artery.

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Therefore,

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an arteriogram was performed fortunately.

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It was only a acute tubular necrosis which

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rapidly cleared here.

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You can see

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that the outline of the kidney is very nicely

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depicted.

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The small temporary cortical vessels are filling.

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There's no spasm of the vessels of the vessels,

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there's no beating.

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In the same series of studies.

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We thought we see a very nice Neffa

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graham.

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And another side benefit is that you

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can see the renal veins.

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This was what we would have to clear.

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This is what the radiological libertarian.

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We also call a normal arteriogram and a transplant

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patient.

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The following slide is that of a young 23 year old male

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who received a living related draft

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and experienced an acute the an old set of acute

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rejection approximately two weeks following the transplant

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prior to that time.

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His function had been quite adequate.

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Despite rather intensive

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anti rejection therapy,

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his function did not improve

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approximately a week and a half,

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a week and a half into his acute rejection course.

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His urine output was very low and his

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crafting and be um,

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are continuing to climb to determine

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if increasing our our continuing the

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the rejection therapy was indicated.

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We felt that an arteriogram might give us some information.

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As you see on this arteriogram,

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there is some stretching of the vessels.

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There is loss of that nice cortical outline that we saw

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in the normal study by loss of flow into the

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Treasury temporary vessels

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from the results of this arteriogram,

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we thought that we still had a salvageable graft.

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But unfortunately,

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that did not prove to be the case.

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And the young man lost his kidney several weeks later.

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The next arteriogram is that of a

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young 19 year old male who received a one energy match

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cadaver kidney,

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who experienced a rather acute

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on a rather acute rejection episode

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approximately one week following the transplant,

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that was reversed by increasing his steroid

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therapy.

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Following a tapering of the drugs he immediately

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rejected again.

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And at that point in time we instigated,

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we instituted uh again,

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repeat increased steroid

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uh therapy and

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he failed to respond to this again,

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we utilized our terry og ra fee to see if we had a graph that was

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worth continuing

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continuing the rejection

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therapy this young man shows.

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And fair,

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I think you can see this beating of

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the secondary vessels of his

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graft,

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pruning of the vessels,

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but no particular arterial spasm.

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Again,

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we felt that this kidney might be salvageable.

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But unfortunately,

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he too went on to reject his kidney when

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it became apparent that our immune suppressive

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therapy was inadequate.

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And we ceased it.

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The following slide is an arteriogram of a

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34 year old female who received a two energy

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match cadaver graft,

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who experienced a rather marked onset of

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acute rejection going from apparently normal

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function to complete allegory Yuria.

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In two days accompanied by high spiking fevers.

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An arteriogram was likewise performed on her when

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our immune suppressive therapy appeared not to have

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any effect and she was returned to dialysis.

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In this particular study,

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you can see mark spasm of the arenal

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artery going into the arena to the bifurcation of the

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arenal main renal artery into its branches.

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This may be a very ominous sign because this young lady

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rapidly lost her graph despite our efforts

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of trying to save it.

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An intravenous polygram can on occasions also be

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very helpful in diagnosing early

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rejection.

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Fortunately,

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we had a nice situation in which to see.

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This is something that is not usually seen.

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This is an ivp from a

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21 year old male who received a two engine match,

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living-related kidney.

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As standard in our program,

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we obtain an IVP on the fifth post update,

15:00.930 --> 15:03.830
hoping to get a good study of the your it'll

15:03.830 --> 15:06.510
anatomy or the collecting system before rejection

15:06.510 --> 15:09.130
occurs so that we can at least rule out

15:09.140 --> 15:11.210
or uh have

15:11.220 --> 15:14.150
some security in the fact that we don't have a

15:14.150 --> 15:17.100
severe anatomical problem in this

15:17.100 --> 15:18.170
particular situation.

15:18.170 --> 15:19.210
This particular patient,

15:19.210 --> 15:21.890
he had a functional obstruction of the ureter

15:21.900 --> 15:24.600
mile but probably secondary to your

15:24.600 --> 15:26.840
eternal edema at the systematic site

15:27.460 --> 15:29.400
resulting in a mouth hydro Euro.

15:29.400 --> 15:32.390
To the striking thing is that all of the pelvis and the

15:32.390 --> 15:33.630
Euro to dilated.

15:33.640 --> 15:35.530
There's no dilatation of the calluses,

15:35.530 --> 15:37.590
which one normally would expect to see.

15:37.600 --> 15:40.330
But you can if I think you can pick it out on this,

15:40.330 --> 15:43.180
there is marked edema of the remote capella

15:44.270 --> 15:46.830
which at the time we weren't sure what this meant.

15:46.840 --> 15:49.640
But two days later we were quite certain what it meant is he

15:49.650 --> 15:51.430
developed a rising B.

15:51.430 --> 15:52.980
One and creatinine where they fall in.

15:52.980 --> 15:55.840
His creatinine clearance slides off.

15:55.850 --> 15:56.220
Please.

15:59.180 --> 16:01.870
Despite all of these manipulations

16:01.870 --> 16:03.030
methods etcetera.

16:03.040 --> 16:04.980
Making the diagnosis of rejection,

16:05.120 --> 16:07.840
we're still depending upon rather severe changes in the

16:07.840 --> 16:10.600
graft uh as depicted by its

16:10.600 --> 16:13.300
function before we can make the diagnosis and

16:13.460 --> 16:15.230
institute therapy,

16:15.240 --> 16:17.680
there's no doubt that we're losing some

16:17.690 --> 16:20.100
some areas of the graph that we will probably never

16:20.100 --> 16:20.740
recover.

16:21.580 --> 16:24.490
Therefore it is imperative that we continue to search

16:24.490 --> 16:26.540
for better methods of detecting rejection.

16:26.540 --> 16:29.510
And there is some probable hope in the gemological studies

16:29.510 --> 16:31.150
that we mentioned earlier this morning

16:32.340 --> 16:34.430
diagnosis of rejection

16:35.380 --> 16:36.150
with john D.

16:36.150 --> 16:37.850
Well call Lieutenant Colonel U.

16:37.850 --> 16:38.020
S.

16:38.020 --> 16:40.740
Air Force Medical Corps Chief transplant

16:40.740 --> 16:41.100
unit,

16:41.110 --> 16:41.920
Wilford Hall U.

16:41.920 --> 16:42.080
S.

16:42.080 --> 16:43.360
Air Force Medical Center.

16:43.370 --> 16:44.820
Lackland Air Force Base

16:46.600 --> 16:49.450
was produced through the mobile facilities of the television

16:49.450 --> 16:51.600
division Academy of Health Sciences,

16:51.600 --> 16:54.130
United States Army Fort Sam Houston

16:54.130 --> 16:54.770
texas