Campath-1H has been used successfully for induction and has resulted in a low rate of acute cellular rejection (ACR) in renal transplantation in combination with various postoperative immunosuppression regimens. This study was undertaken to investigate the extent of monocyte involvement in ACR, with or without Campath-1H induction. We found that monocytes represented the majority of inflammatory cells in grades Ib or higher ACR, but not with Ia type of ACR, regardless of the status of Campath-1H induction. Cases of ACR, following Campath-1H induction, appear to demonstrate a 'pure form' of monocytic ACR, whereas monocytes were mixed with many other types of inflammatory cells in the cases of ACR in the absence of Campath-1H induction. In addition with Campath-1H induction, the cases of monocytepredominant ACR were found to uniformly exhibit a good response to corticosteroid treatment. We conclude that monocyte-predominate ACR may represent a severe form of rejection, with or without Campath-1H treatment.

Within the past year at our transplant center we have had the experience of performing renal allografts in two patients older than 65 years, each of whom had been on hemodialysis more than 10 years. Both resulted in patient mortality within 90 days of transplant (one due to myocardial infarction, the other due to visceral ischemia with infarction). This prompted us to review retrospectively our own data (n = 204) and the national (UNOS) data (n = 10 971) regarding transplant outcome, patient age, and length of time on dialysis prior to renal transplantation. This review revealed that patient mortality after transplant increased with the length of end-stage renal disease (dialysis, regardless of type) independent of age, the greatest mortality occurring within the first 6 months of transplant (and not thereafter); graft survival was similar for all age cohorts analyzed. Our review of the literature reveals a paucity of articles pertaining to posttransplant mortality and length of time on dialysis prior to transplant. Our results indicate the following possible conclusions. (1) The length of time of end-stage renal disease therapy prior to renal transplantation is a significant and independent risk factor for post-transplant mortality.(2) Higher priority should be given to this factor when formulating strategies for allocation of scarce resources. (3) Patients on dialysis for extended periods of time who arc elderly may be at particularly high risk. (4) Patients being considered for renal transplant should be informed of their individual risk factors for mortality post-transplant based on length of ESRD therapy. (5) Renal transplantation should be considered as early as possible in patients with ESRD (or imminent ESRD).Within the past year, we have experienced several deaths of renal transplant recipients, each of whom had been on Offprint requests to: hemodialysis for extended periods of time prior to transplantation. This prompted us to review retrospectively our own data (n = 204) and the UNOS data (n = 10 971) regarding the effect of length of end-stage renal disease (ESRD) prior to transplantation on patient survival following allografting.Many factors have been suggested to affect survival following renal transplantation, including recipient age, donor source (cadaver, LRD unrelated) and age, HLA matching, immunosuppressive regimen, and various other pretransplant conditions (e.g. cardiac status, presence or absence of diabetes mellitus, PRA, prior transplant, etc.). To our knowledge, length of time of ESRD prior to transplantation and its impact on patient survival have neither been previously emphasized nor systematically examined. Materials and methods

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Because coronary artery disease is the leading cause of death in patients with end-stage renal disease, we prospectively studied the prognostic value of dobutamine stress echocardiography (DSE) compared to coronary angiography (CA) as an evaluative tool. Thirty-three patients at high risk for coronary artery disease were selected from a cohort of 133 renal transplant candidates and underwent both DSE and CA. In this study, the value of DSE was found to exist in its strong negative predictive value (92%). A negative DSE coupled with a negative clinical cardiac evaluation was found to practicably exclude the necessity for CA. DSE can thus serve as a non-invasive, low cost screening test.

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