Transoperative Renal Intraarterial Verapamil in Kidney Transplantation Decreases Acute Tubular Necrosis F. Lo ´ pez-Neblina, H. Jime ´ nez, I. Finkelstein London, B. Gonzalo Valdez, and A. Luis Mauro Arteaga Barcaz V ERAPAMIL is a calcium channel blocker; our group has demonstrated in several papers the beneficial effect of verapamil alone or combined in renal ischemia- reperfusion in experimental studies. 1–3 Acute tubular ne- crosis (ATN) is secondary to ischemia/reperfusion damage, probably through the activation of several enzymatic path- ways involved in inflammatory response such as the expres- sion of adhesion molecules and the production of free radicals due to activation of calcium-dependent enzymes. 3 We present our clinical experience with our transopera- tive prophylactic therapy to avoid ATN through the admin- istration of renal intraarterial verapamil as a part of the high efficiency kidney transplantation program (HEKT). MATERIAL AND METHODS All patients that received a living-donor graft performed in Me ´xico in whom renal intraarterial verapamil has been used as a part of the transoperative management in the high efficiency kidney transplant program have been included. The verapamil has been administered during the first seconds after reperfusion. The injection was done with a 5-mL syringe with a 27-gauge needle. We administered 5 mg of verapamil clorhydrate slowly directly into the graft renal artery. RESULTS We have performed 51 kidney transplants using intraarte- rial verapamil (32 LRD and 19 LNRD; aged 9 to 59 yr, 34 average). In all cases the allograft was subject to 3 hrs of cold preservation in Custodiol (14) or in Eurocollins (37). No patient has presented important hypotension or bradi- cardia nor required the suspension of administration of verapamil. In all cases the central venous pressure (CVP) is maintained between 15 to 18 cm of water previous to the anastomosis and reperfusion. After the administration the CVP goes down slightly 3 to 4 cm, but in 3 to 5 minutes it returns to previous values. Only one patient developed ATN, and we believe it was related to the presentation of hypothyroidism in the early postoperative period. She re- covered the renal function and at 2 years she has normal kidney function. CONCLUSIONS ATN is present in 10 to 20% of kidney recipients from live related or nonrelated donors, and it increases up to 30 to 50% in cadaveric graft transplantation in several reports in the literature. 4–6 In our series ATN was present only in 1 of 51 cases, which is 1.9%. This result is better than that reported in the literature. The beneficial effect of the intraarterial verapamil in the transoperative procedure may be due to several factors: first, a direct immediate vasodi- lation in the renal vasculature; second, a blockade of the calcium channels, which decreases the enzymatic pathways responsible of ischemic damage (such as lipases); and third, probably this enzymatic block decreases the expression of adhesion molecules as well as the expression of other mediators such as the arachidonic acid products and cito- kines. All the potential pathways could be the reason for the beneficial effect that we have observed with our transurgical treatment with verapamil directly into the allograft renal artery. REFERENCES 1. Lo ´pez-Neblina F, Toledo-Pereyra LH, Suzuki S, et al: J Invest Surg 8:57, 1995 2. Lo ´pez-Neblina F, Toledo-Pereyra LH: Cirujano General 16: 149, 1994 3. Lo ´pez-Neblina F, Paez A, Toledo-Pereyra, et al: J Surg Res 61:469, 1996 4. Anderson CB, Michie CA, Etheredge EE: Surg Gynecol Obstet 149:697, 1979 5. Brophy D, Najarian JS, Kjellstrand CM: Transplantation 29:245, 1980 6. Kreis H, Finch TW, Moreau JF, et al: Adv Nephrol Necker Hosp 8:209, 1979 From the Trasplantes de Me ´ xico & Centro Me ´ dico Nacional del Noroeste del IMSS, Me ´ xico. Address reprint requests to Dr L.N. Fernando, Puebla #334 Sur Col Centro, CD, Obregon Son, Mexico. 0041-1345/99/$–see front matter © 1999 by Elsevier Science Inc. PII S0041-1345(99)00656-9 655 Avenue of the Americas, New York, NY 10010 3030 Transplantation Proceedings, 31, 3030 (1999)