A 62-year-old man presented with acute abdominal and flank pain, oligoanuria and severe acute kidney injury. Unenhanced CT imaging did not detect urolithiasis or hydronephrosis. There was an early blood pressure surge followed by an intense inflammatory response, with a rise in peripheral blood leucocytes and C reactive protein. His urinalysis was bland but the serum lactate dehydrogenase was markedly elevated. CT angiograms demonstrated multiple pulmonary emboli and bilateral renal artery thromboembolism, with occlusion of the left main renal artery. Despite an 88-hour delay from pain onset, catheter-directed thrombolysis and thromboaspiration of both renal arteries were successfully performed, allowing the patient to recover enough kidney function to cease haemodialysis. A patent foramen ovale with right-to-left shunting was discovered, and paradoxical embolism was suspected as the cause of renal infarction. The benefit of catheter-directed reperfusion after prolonged bilateral renal ischaemia is not easily predicted by the severity or duration of acute kidney injury alone.

INTRODUCTION.-We analize our results in 100 consecutive first kidney transplants that maintained function for at least one month and were followed for 4 to 6 years. METHODS.-Immunosuppression included Tacrolimus and Mycophenolate Mofetil in all patients. The first 51 transplants (Group S) received either Thymoglobulin or Daclizumab as induction therapy and long term steroids. The next 49 transplants (Group NS) Daclizumab as induction and sterois on only days 0 and 1 post-transplant. All patients were followed for 48 months and up to 98 months (mean 82 m. in S vs 62 m. in NS) RESULTS.-Age, sex, race and original disease was similar in both groups. African/American race (A/A) was 33% in NS vs 31% in S. Cadaver donor type was also similar, 21% ECD and 26% DCD in Group S vs 21% and 25% in Group NS. Incidence of delayed graft function (DGF) was 29%in S vs 36% in NS. One year patient and graft survival was repectively 96% and 96% in S vs 98% and 96% in NS. Four year actual patient and graft survival was respectively 82.3% and 80% in S vs 91.8% and 85.7% in NS. Six patients had acute cellular rejection (ACR), one in S (2%) and 5 in NS (10%). All episodes but one were diagnosed by protocol biopsies in patients with DGF and were reversed by steroid therapy only. The main cause of graft loss was death with functionong graft (DWF) and onle 2 patients in each group (4%) developed chronic allograft nephropathy (CAN) leading to graft failure. The cause of death was similar in both groups except for infection that was more prevalent in group S (3 patients vs 0). The incidence of new onset diabetes (NOD) was 20% in S vs 4% in NS. CONCLUSIONS.-1.-Kidney transplantation without sterois has provided excellent one and four year patient and graft survival in our program. 2.-Although there was a slight increase in ACR in Group NS, it did not translate in higher CAN or graft failure and, in most cases was mild and easily reversible with steroids. 3.-There seemed to be a trend toward less NOD, severe sepsis and post-transplant weight gain although a larger series and longer follow-up is needed to validate the long term benefit of steroid avoidance. 4.-Patient satisfaction has increased dramatically since the institution of this protocol at our program six years ago.