Shwartzman reaction after human renal homotransplantation.

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. ECENTLY. tliere h i ~ v e I)eeli s e v e r i t 1 reports of R " l i y l ) e n l n t t e r e j ec t io l , " i l f t e r I ~ I I I I I ~ ~ I I r e t l i ~ l 11ot11ot r i u n s l ) l a n t a t i o ~ l . 111 some o f these cases t h e h o ~ l l o g n ~ t ' t s ~ t s t a i n e t l 2111 i r r e l ) i ~ n t l ) l e i n i ~ ~ r \ . w l ~ i l e the I);I.. . t i e n t was s t i l l on the o p e r a t i ~ l g t;il)le.l-.' 111 c i i s e s it1 w h i c l ~ mqior red-cell g r o u l ) c o ~ n l ) i ~ t i l ) i l i t y e x i s t e t l 'From the Dep:lrtmen~ of Surgery. Univer\ity of <'olor;ldo School of Medic~ne ilnd the Denver Veter;lns Admln~htritt~on Ho\p~li~l. Denver. Coloritdo. the Depilrtmenl of Exper~mentill 1';ttholopv. Scripp\ Cllnic and Keseiirch Founditllon. 1.ii Jollit. C;tliforni;i. and he Depiirtment ol' Surgery. School of Medlc~ne. Univerh~ty of ('nliforniii. L.o\ Anpele\ 1;lddress reprlnt reque\r\ to Dr. St;irzl ;I{ Veteran\ Admini\rr;llion Ho\pltiil. 1055 Clermonl Street. Denver. C'olorildo XO??O). This IS publicat~on No. 261 from the Scr~pp\ ('linlc ;ind Keheitrch toundation. Supported hy prilntr (AM-061X3. AX1-06344. HF-07735. A M 07771. AI-04 151. FK-0005 I . FK-00069. tO5-TWI 154. AI-07007 and 5TI CiM6X3): from the Un~led Sti~te\ Puhlic He;lllh Serv~ce by AEC Contrnct AT 104-3)-410 :~nd hv AID Contnlct PH 436ZY94. 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 pretormed lymphocytotoxic antibodies. Thus, certain patients may be predisposed. High-risk patients should be recognized and treated prophylactically with anticoagulants. 1)etween t h e t l o n o r s i u i t l r e c i p i e n t s , s u c l ~ ;I c o ~ ~ ~ p l i c a t i o n w i t s n o t recognized ill the first 180 c; ises ol' renal t r a t l s l ) l ; l ~ ~ t ; l t i o ~ ~ at the U n i v e r s i t y o f C o l o r i t t l o . T h e n , w i t h i n it11 i n t e r v a l o f s i x a11t1 ;I Iialf weeks, f i v e l i o n l o g r a f t s were t l e s t r o y e t l i n three p a t i e n t s w i t h i n n ~ i ~ n r t t e s or hours a f t e r t h e i r r e v ; l s c i t l i i r i z i ~ t i o ~ ~ . I t 11i1s I ) e e l ~ s ~ g g e s t e t l ~ ~ th i i t these i ~ l ~ ~ ~ ~ e d i i ~ t e d i s i ~ s t e r s were due to the d i r e c t c y t o t o x i c i l c t i o l ~ of ~ ) r e t i ) r m e t l ; l l ~ t i l ) o t l i e s ill the host that r e i l c t e t l i l g a i l ~ s t l i i s toco~~~l) i~t i l ) i l i ty i111tige11s present ill the t l ; rns l ) la l l ted L i d n e ? , . The state of ; l t l v i lnce s e n s i t i z i l t ion t o these s p e c i f i c i ~ l ~ t i ~ e t l s was p r e s u n ~ u l ) l ~ i n t l ~ t c e t l d u r i n g the course of 111111til)le ~ ) r e g t n i u i c i e s , I)!. t h e p r e v i o u s a d ~ n i ~ n i s t r a t i o l i o f n ~ a l t i p l e I ) l oo t l t r i u ~ z t 'us iot ls o r I)y o t h e r m e i u l s s r t c h as p r i o r renal I ~ o m o triunsl)l:untatiot~. \Vhere l x ~ t h o l o g i c a l r e p o r t s were Rcprintrd from the New England Journal of Medicine 270:G42-648 (March 2 1 ) . 1968 given, the morlIliologic conseclueltce of the sttpposetl iicrlte ;r~ltipen-iuitil)o(I!~ reactions i n c l t ~ d e d extensive tlestrrtction of t h e Iiontogriift vi tsct t l i t t t~re.~-~ 111 the Ilomografts of our o w n pittients, the most striking finding wits extensive intrirvitsct~lar tlelIosition of f i l~r in, citusing occltlsion of ~ i ios t of the glomerulitr capillaries iintl conseclllent cortical necrosis exactly a s occurs in t h e experimental generalized Shwartznlan reaction.5 T h e r e was little o r no host i m n ~ t ~ ~ i o g l o l ~ u l i n deposition in t h e five kidneys removed 2-1 honrs to eight weeks after transplan-