SHWARTZMAN REACTION AFTER HUMAN RENAL HOMOTRANSPLANTATION<sup>*</sup>

T Starzl

R Lerner

F Dixon

C Groth

L Brettschneider

P Terasaki

address reprint requests to Dr. Starzl at Veterans Administration Hospital, 1055 Clermont Street, Denver, Colorado 80220

^{From the Department of Surgery, University of Colorado School of Medicine and the Denver Veterans Administration Hospital, Denver, Colorado, the Department of Experimental Pathology. Scripps Clinic and Research Foundation, La Jolla, California, and the Department of Surgery, School of Medicine, University of California, Los Angeles}

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.

Abstract

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.¹4 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 suggested²4 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.²4

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.

Recognition that this complication may occur is important for several reasons. In the first place, experimental observations and the present clinical experience indicate that the Shwartzman reaction can be prevented and even in part reversed with appropriate anticoagulant or fibrinolytic therapy. Secondly, several factors that may contribute to its development can be eliminated or at least minimized by attention to details of preoperative care. Finally, the failure of function of a kidney involved in the Shwartzman reaction should not necessarily be attributed to a poor histocompatibility match since a variety of other immunologic and nonimmunologic factors may be contributory.

Footnotes

This is publication No. 261 from the Scripps Clinic and Research Foundation.

Footnotes

REFERENCES

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