Shwartzman Reaction after Human Renal Homotransplantation

Abstract

In three human recipients, five renal homografts were destroyed within a few minutes to hours after their revascularization in the new host. The kidneys, removed one to 54 days later, had cortical necrosis. The major vessels were patent, but the arterioles and glomeruli were the site of fibrin deposition. There was little or no fixation of host immunoglobulins in the homografts. The findings were characteristic of a generalized Shwartzman reaction.Although the cause (or causes) of the Shwartzman reaction in our patients is not known, they may have been conditioned by the bacterial contamination and hemolysis that often attend hemodialysis, by immunosuppression and by the transplantation itself. Some of the patients have preformed lymphocytotoxic antibodies. Thus, certain patients may be predisposed. High-risk patients should be recognized and treated prophylactically with anticoagulants.Recently, there have been several reports of "hyperacute rejection" after human renal homotransplantation. In some of these cases the homograft sustained an irreparable injury while the patient was still on the operating table. [1][2][3][4] In cases in which major red-cell group compatibility existed between the donors and recipients, such a complication was not recognized in the first 180 cases of renal transplantation at the University of Colorado. Then, within an interval of six and a half weeks, five homografts were destroyed in three patients within minutes or hours after their revascularization.It has been suggested 2-4 that these immediate disasters were due to the direct cytotoxic action of preformed antibodies in the host that reacted against histocompatibility antigens present in the transplanted kidney. The state of advance sensitization to these specific antigens was presumably induced during the course of multiple pregnancies, by the previous administration of multiple blood transfusions or by other means such as prior renal homotransplantation. Where pathological reports were given, the morphologic consequence of the supposed acute antigen-antibody reactions included extensive destruction of the homograft vasculature. [2][3][4] In the homografts of our own patients, the most striking finding was extensive intravascular deposition of fibrin, causing occlusion of most of the glomerular capillaries and consequent cortical necrosis exactly as occurs in the experimental generalized Shwartzman reaction. 5 There was little or no host immunoglobulin deposition in the five kidneys removed 24 hours to eight weeks after transplantation.

Positive Lymphocytotoxic Crossmatch Does Not Adversely Affect Survival in Living Donor Liver Transplantation

“…The crossmatch test is mandatory for kidney or heart transplantation because transplantation of a kidney or heart into a recipient with a positive crossmatch against the donor almost always causes a hyperacute rejection [2,3]. …”

Xenogene Aortensegmenttransplantationen mit Inzuchtratten

“…Fiir die hyperakute Abstogung von Herz und Nieren hat neben humoralen Faktoren die intravaskul/~re Gerinnung nachweisbare Bedeutung (Jamieson, 1974;Catell a. Jamieson, 1975;Kissmeyer-Nielson et al, 1966;Starzl et al, 1968) und ftihrt zur Zerst6rung des Endothels und zur leukozyt/iren Infiltration (Williams et al, 1968;Busch et al, 1971;Schilling et al, 1975). Fiir die beiden Organe gibt es gut meBbare funktionelle Parameter, n/imlich EKG (Herz) und meBbare Qualit/it und Quantit/it des Urins (Niere), mit deren Hilfe der Zeitpunkt einer vollendeten hyperakuten AbstoBung bestimmt werden kann.…”

“…der von Starzl et al (1968) und Williams et al (1968) beschriebenen hyperakuten AbstoBung von allogenen Es sind zwar nur in 20% der yon uns untersuchten Ratten (n = 20) verschwindend geringe Titer von sogenannten heterophilen Antik6rpern vorhanden, die auf einer Partialantigengemeinschaft mit Mikroorganismen z.B.…”

Early clinical xenotransplantation experiences—An interview with Thomas E. Starzl, MD, PhD

“…He was one of the first to document hyperacute rejection of a kidney allograft (4), and also to report the development of a coagulopathy after allotransplantation (5) – both pathologic conditions that are of great interest and relevance to those of us in xenotransplantation research today.…”