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.

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