Book Review

Renal Transplantation

N Engl J Med 1998; 338:1779-1780June 11, 1998

Article

Renal Transplantation
By Ron Shapiro, Richard L. Simmons, and Thomas E. Starzl. Stamford, Conn., Appleton & Lange, 1997. 572 pp., illustrated. $100. ISBN: 0-8385-8383-0

With more than 20,000 kidney transplantations performed yearly and more than 150,000 patients alive with a functioning kidney transplant each worldwide, renal transplantation is nowadays a major activity for many nephrologists and transplant surgeons. Considering that general practitioners and trainees in academic hospitals are increasingly confronted with the complications of the procedure and the ensuing immunosuppression, the audience for books on renal transplantation is large. Written by pioneers in the field at the University of Pittsburgh, Renal Transplantation was conceived to cover both the basic principles and the clinical aspects of the discipline.

The book begins with an overview of the main factors affecting the survival of renal allografts, such as previous transplantation, HLA sensitization, and delayed graft function. The historical chapter explains in a lively manner how the advances in surgery and transplant immunology allowed renal transplantation to evolve from a heroic procedure to a routine clinical practice. The breakthrough provided by the combined use of purine analogues and glucocorticoids as chemical immunosuppressants is appropriately underscored. The personal contribution of Dr. Starzl to the history of renal transplantation is reflected by his authorship of 28 of the 116 references cited in this chapter.

The book is organized in a logical manner, from the initial assessment of candidates for transplantation to the long-term complications of the procedure. The discussion of the pretransplantation evaluation of potential recipients provides clear information about important topics, such as the cardiac status of older patients, the recurrence of primary renal diseases in the transplant, and the care of patients with previous cancers. After the description of kidney procurement from cadaveric and living donors, the surgical aspects of renal transplantation are extensively and beautifully covered. The back-table preparation of the renal vessels is clearly explained and illustrated, as well as the implantation procedure and the techniques of vascular and ureteral reimplantation. Since immediate function of the transplanted kidney positively influences its long-term survival, guidelines for the perioperative management of volemia would have been useful.

The book then proceeds to address the key issues related to renal-allograft rejection. The role of preoperative histocompatibility testing and crossmatching in preventing rejection is emphasized, but a few relevant points are overlooked, such as HLA genotyping, the significance of a positive B-cell crossmatch, and the concept of permissible HLA mismatches. The information about immunosuppressive drugs for the prevention and treatment of rejection is rather exhaustive; however, it would have been interesting to include the author's views on such practical issues as the indications for induction therapy with antilymphocyte antibodies, the choice between cyclosporine and tacrolimus, and the place of mycophenolate mofetil. With regard to the histologic evaluation of the transplanted kidney, the basic lesions of hyperacute, acute, and chronic rejection are well described, but a description of the Banff scheme widely used for grading rejection would have been appreciated.

Surgical complications, such as urinary obstruction and arterial and venous thromboses, are covered perfectly, with emphasis on practical aspects of their diagnosis and treatment. As far as medical complications are concerned, infections are generally well discussed, although the use of new nucleoside analogues for the treatment of infections with the hepatitis B virus could have been mentioned. The section on cancer adequately draws attention to this disease as a major threat to kidney-transplant recipients. The reader will find further practical information on radiologic evaluation and specific problems related to pediatric transplantation, multiorgan transplantation, and pregnancy in kidney-transplant recipients. The book ends with a discussion of xenotransplantation and other future prospects in the field.

Altogether, Renal Transplantation represents a valuable contribution to an emerging subspecialty in clinical medicine. It will provide useful and up-to-date information to all physicians involved in the care of kidney-transplant recipients.

Daniel Abramowicz, M.D.
Michel Goldman, M.D.
Université Libre de Bruxelles, B-1070 Brussels, Belgium