Search

In order to evaluate morbidity and mortality after elective resection of abdominal aortic aneurysms (AAA) as it relates to aneurysm size, a retrospective review of 111 elective aneurysmectomies over a 5 year period was undertaken in a VA population. Thirty seven AAA's measured < 5 cm in diameter and 74 were > or = 5 cm by CT scan. Patients with small AAA (S-AAA) were significantly younger (mean 64 years) than those with large AAA (L-AAA) (mean 69 years) (p < 0.003). Both groups were similar with respect to prevalence of cardiovascular, pulmonary and renal disease. Aortic cross-clamping time was significantly shorter in L-AAA, possibly because those with S-AAA had a higher prevalence of associated occlusive disease requiring more femoral anastomoses (p < 0.04). Postoperatively six patients (8%) had a myocardial infarction (MI) in the L-AAA group and four (5%) of these died. In contrast no patient with S-AAA suffered a postoperative MI. The rates of non-cardiac complications and length of hospital stay were not significantly different between the two groups. However, the patients with L-AAA stayed longer in ICU (p < 0.05) and the overall combined morbidity rate was significantly higher in this group (p < 0.02). Our results suggest that resection of S-AAA upon diagnosis in acceptable risk patients appears to be the safest overall therapeutic plan.

Two cases of renal allotransplants are presented with urologic complications caused by the spermatic cord. Management of these patients is discussed, and a question is raised about the insistence of placing the ureter under the spermatic cord in all cases.

A kidney transplant patient developed recurrent hypertension on two successive occasions associated with lesions of the renal artery. The first episode of hypertension was caused by renal artery stenosis and was surgically corrected; the second was caused by a sizable pseudoaneurysm at the site of arterial anastomosis which was resected, and arterial continuity was successfully re-established.

A patient with end-stage renal disease had erythrocytosis after kidney transplantation, with a hematocrit level that ranged between 52 and 60%. Selective catheterization of venous blood from his native kidneys and the transplanted kidney revealed a threefold increase of erythropoietin activity in blood from his own kidney over systemic blood and blood from the transplanted kidney. Bilateral nephrectomy cured the condition. Postoperative hematocrit and erythropoietin levels were within normal limits.

The development of erythrocytosis following renal transplantation has been reported to be caused by a number of factors. These include acute and chronic rejection, hydronephrosis and renal artery stenosis. In this study, seven patients were noted to have erythrocytosis with hematocrits ranging between 53.5 and 66%. Serum erythropoietin levels were elevated and ranged between 11 and 60 mU/ml with a mean of 31.9 mU/ml in six of seven patients. Selective catheterization of veins of native and transplanted kidneys in three patients revealed mean serum levels of 40.9 and 13.0 mU/ml, respectively. This suggests that excess erythropoietin is being produced from the diseased native kidneys. Bilateral nephrectomy in one patient cured erythrocytosis and dropped systemic levels of erythropoietin (EP) to 6.1 mU/ml. In four of the remaining five patients, hematocrits came down spontaneously to within normal over a 1- to 3-year period. Consequently, it appears that in a number of transplant patients the retained diseased kidneys, having lost all excretory and concentrating function, may remain capable of functioning as endocrine erythropoietin-producing organs.

The case history of a 30-year-old male kidney transplant patient who developed cutaneous protothecosis is presented. The lesions, initially located over the forearm and around the site of previous AV shunt, consisted of maculopapular areas which opened spontaneously and drained purulent sanguineous material. Culutre of drainage grew Prototheca wickerhamii. Other virulent organisms, ie. Klebsiella pneumoniae and Pseudomonas aeruginosa, were also grown. The patient died of Klebsiella septicemia and shock. Protothecosis is an uncommon algal infection in man. This is the first report of the disease among recipients of a renal transplant.

Infections complicated the course of 59 of 111 renal transplantations (53%) performed on 93 patients at the University of Maryland Hospital. Infections and resultant deaths were more common among the patients with cadaver transplants. The transplant wound and the urinary tract were the most common sites of infection, occurring in 33% and 24% respectively. Septicemia developed in 11 patients (10%), secondary to urinary tract infection in six and to surgical wound infection in three. Opportunistic viral, fungal, and actinomycotic infections occurred in ten patients (9%). A total of nine patients (8%) died as a result of infection. This experience with sepsis and mortality, substantially lower than previously reported, may have resulted from (1) rigorous screening and detailed histories of recipients and donors for infection at the time of transplantation, as well as bacteriologic and serologic studies; (2) discontinuation of azathioprine whenever the WBC fell to less than 5,000/cu mm; (3) aggressive surveillance and early management of infections; and (4) prompt removal of a nonviable kidney when detected by radionuclide scan and percutaneous renal biopsy.