Search

A computer analysis of post renal transplantation gastrointestinal problems was performed to identify important associated clinical factors. Thirty-seven per cent of all transplant recipients developed one or more significant problems. Hemorrhage, nondiverticular intestinal perforation, and esophagitis occurred most frequently in hospitalized patients. Pancreatitis, diverticulitis, and gastroduodenal perforation occurred characteristically in long-term survivors with well functioning allografts. Eleven of 32 HLA identical recipients treated with maintenance corticosteroids during stable kidney function developed gastrointestinal disease while only one of 13 HLA identical recipients not given maintenance steroids developed a problem, which strongly suggests a causal role for steroids in the development of late complications. The association of preexisting peptic ulcer and diverticular disease with hemorrhage and perforation supports previous recommendations that documented peptic ulcer disease or diverticulitis should be corrected surgically prior to transplantation.

SUMMARY A renal transplant recipient developed antibodies reactive with the tubular basement membrane (TBM) but not glomerular basement membrane of two successive renal allografts. The specificity of the anti-TBM antibodies was confirmed by elution and absorption studies. The antibodies did not react with the patient's native kidney, suggesting that the immune response had been induced by the introduction of a TBM antigen through transplantation. Strain-specific TBM antigens have previously been identified in rats, and antibodies to these antigens can be induced by appropriate cross strain transplantation, supporting a similar hypothesis in this patient.

Transluminal angioplasty of venous stenoses in polytetrafluoroethylene vascular access grafts. Since 1984, percutaneous transluminal angioplasty (PTA) utilizing high pressure balloon catheters has been used as an initial approach to restore patency of PTFE (polytetrafluoroethylene, GORE-TEX) hemodialysis vascular access grafts. Seventeen stenotic lesions detected by fistulogram underwent elective PTA. Twelve of these lesions were detected after thrombectomy and five were detected because of increased venous pressures during dialysis. Fourteen attempts at PTA were completely successful in restoring functional patency to the vascular graft. Three attempts were unsuccessful; two of these three grafts were subsequently repaired surgically. Venous stenoses that extended for greater than 6 cm were not considered for PTA. We conclude that PTA is a technique of promise in the non-surgical salvage of failing PTFE grafts. PTA can prolong the useful life of PTFE vascular access grafts and can be performed on an outpatient basis, eliminating the hospitalization that is usually required for surgical revision.

Immunologic enhancement was employed to circumvent fatal acute graft-versus-host disease after incompatible bone-marrow transplants given an infant with severe combined immunodeficiency. Maternal plasma contained lymphocytotoxic antibodies to paternal and patient lymphocytes and blocked mixed leukocyte responsiveness of maternal cells against mitomycin-C-treated paternal or patient cells. The infant was treated with maternal plasma before and after infusions of 5 X 106 per kilogram of maternal bone-marrow cells on two occasions. After each cell infusion dramatic weight gain and resolution of infections occurred. Improved immunologic capacity was manifested by development of delayed cutaneous responsiveness to candida antigen from the 13th day after transplant and later rises in serum IgG, IgA, and IgM concentrations; immunologic capacity was not increased by implantation of a fetal thymus nine months later. This infant's survival for 14 months after transplant, the longest known among patients wi...

(1) A twelve-hour period of total body hypothermia in the recipient in the early post-grafting period was associated with a prolongation of survival of skin allografts in rats.(2) This effect was greatest when hypothermia was induced beginning twenty-four hours after grafting, but some effect was evident when the hypother-mia was induced immediately after grafting or seventy-two hours after grafting.(3) The lymphopenia that results from prolonged hypothermia may play a role in the effect observed.

DIASTOLIC hypertension has been described in a variety of clinical settings after bilateral nephrectomy and renal transplantation in man.1 2 3 Although its exact etiology has not been clarified, its persistence or reappearance has usually been attributed to overexpansion of the intravascular volume or ischemic injury to the allograft during a period of threatened immunologic rejection. The present report describes the severe but transient accentuation of hypertension during the immediate postoperative period in association with probable ischemia of the graft from mechanical causes and its subsequent reappearance during a period of suspected allograft rejection. On both occasions the presence of hypertension was . . .

The immunogenicity of the haplotypes in 30 families was measured by survival of skin grafts between selected paired family members. These families were genotyped for HL-A using 57 selected cytotoxic alloantisera defining HL-A 1–12 as well as other nondefined specificities. Mixed leukocyte reactions were also studied in this series and the correlations between the mixed leukocyte reactions with skin graft survival times, individual HL-A specificities, and the number of incompatible HL-A alleles are reported. Comments concerning the interpretation and quantitation of the mixed leukocyte reactions are discussed.

16 patients underwent renal transplantation from a sibling donor who was prospectively determined to be ABO compatible and HL-A identical with the recipient. Unidirectional mixed leukocyte reactions were performed; in each instance, lymphocyte stimulation in either direction was not observed. The plasma creatinine 10-68 months after transplantation in these 16 patients ranged between 0.9 and 1.9 mg/100 ml. The creatinine clearance ranged from 48 to 113 ml/min, and the blood urea nitrogen (BUN) ranged between 12 and 35 mg/100 ml. Urine protein excretion varied from 0.11 to 1.86 g/day. Six patients exhibited no detectable clinical episodes of acute rejection; they were treated with azathioprine alone and each of them demonstrated normal or near normal renal histology when biopsy specimens were obtained more than 6 months after transplantation. Nine patients experienced acute rejection episodes that required the use of steroid therapy. The severity of these rejection episodes was variable; they included a mild reduction in renal function with an immediate steroid-induced restoration of function and eventual discontinuance of steroid therapy to severe reduction in function requiring prolonged and moderate doses of steroids without return to normal renal function. Renal histological observations in this group ranged from mild to marked cellular and structural changes which fit the criteria of the rejection. One patient demonstrated a gradual loss of renal function with heavy proteinuria. Biopsy of this allograft demonstrated the recurrence of original disease, i.e., lobular glomerulonephritis. The marked variability in the clinical course and allograft morphology in these 16 patients could be explained by antigenic differences at non-HL-A loci. The presence of minor histocompatibility loci has been well documented in other mammalian species and they are most certainly present in man. The need for their identification and definition is stressed.

Ultrasonography has become fairly standard for assessing common complications of renal transplantation such as hydronephrosis, urinomas, and lymphoceles. Infarctions are a less common complication that may occur in the setting of transplant rejection. We report a case in which an apparent solid mass on sonography proved to represent normal residual renal parenchyma in a kidney with a small shrunken lower pole due to infarction.

Summary o 1. An experimental lesion is described resembling iliofemoral emboli seen clinically. 2. This lesion has resisted lysis by the methods employed, including regional perfusion with an intensely lytic perfusate.

Double lumen subclavian venous hemodialysis catheters are in wide use in the United States to provide temporary vascular access. The disadvantages of these catheters include a high infection rate and short use-life (2 to 3 weeks). We evaluated a felt cuffed tunnelled jugular venous hemodialysis catheter (PermCath) to determine its ability to overcome these shortcomings and compared it with standard noncuffed double lumen dialysis catheters. Eighty PermCaths were inserted during this prospective study in patients needing temporary vascular access in excess of 1 month. Median use-life of these catheters was 8 weeks with a use range of 3 weeks to 5.4 months. Only four functioning catheters failed before elective removal. Despite the prolonged use-life there was only one episode of catheter mediated bacteremia. Seven catheters (9%) failed to function immediately after insertion. These failures were caused by catheter kinking in the region of the felt cuff. Thrombosis of the catheter lumen was the most frequent complication (137 episodes) but resolved in over 95% of the instances with urokinase instillation. Exit site infections (23 instances) were successfully treated conservatively. We conclude that the PermCath (Quinton Instrument Co, Seattle) is a safe and reliable new device with a low complication rate and a longer use-life than standard subclavian dialysis catheters. This longer use-life allows more time for maturation of primary arteriovenous (AV) fistulas and Tenckhoff peritoneal dialysis catheters, and provides time for the healing of infected vascular access grafts. Its primary disadvantage is the need for surgical insertion.

• A 52-year-old man died during reoperation for bleeding after the development of acute postoperative acalculous cholecystitis. While the liver was being manipulated during surgery, the pulmonary artery diastolic pressure increased suddenly, cardiac output and blood pressure decreased, and soon afterward the patient had a cardiac arrest from which he could not be resuscitated. During resuscitative efforts, the maximum partial arterial oxygen pressure achieved was only 55 mm Hg despite 100% inspired oxygen. At autopsy, bile aggregates were found within necrotic liver parenchyma, portal and central vein branches, and numerous pulmonary arterioles and capillaries. The pulmonary arterial bile most likely resulted from embolization of inspissated hepatic bile aggregates during surgical manipulation. ( Arch Surg 1986;121:1206-1208)

Summary o 1. Twenty-nine dogs were subjected to patch grafts of the inferior vena cava employing patches of woven Teflon or fresh autogenous vein. 2. The most striking difference between the two groups was that the autogenous patches healed with much less scarring and narrowing of the lumen than did the Teflon patches. At three weeks, 8 of 9 autogenous vein patches had healed with little or no narrowing of the lumen, whereas the same was true of only 2 of 15 of the Teflon patches.

The Uniform Anatomical Gift Act, drafted by the Commissioners on Uniform State Laws, provides a comprehensive and modern legal framework for the donation of human organs for medical research, education and therapy. Widespread adoption of the Act, which eliminates existing unnecessary legal formalities, will make available more human tissue for medical purposes. In building the Act on the principles of consent and voluntary donation, the Commissioners recognized and protected other important interests in a dead body. They further recognized that many nonlegal impediments to the procurement of organs exist that cannot be overcome by legislation but must be resolved. Because of this approach, the Act is widely supported by the medical and legal communities and the general public and will soon probably become the law of most states. Such acceptance obviates the need for more radical legislative measures that would eliminate the principles of consent and voluntary donation. Finally, legislation that d...

Introduction The purpose of this paper is to present the experience at the Duke University Medical Center with inferior vena caval ligation for thromboembolic disease. A detailed historical review of inferior vena caval ligation is not intended, since a comprehensive review of the subject was recently published by Dale. 1 In this discussion, special emphasis is given to (1) the indications for vena caval ligation; (2) venous pressure studies as a guide to the physiologic effect of ligation in the individual patient; (3) phlebography to outline the extent of venous occlusive disease; (4) immediate postoperative complications, and (5) late sequelae and long-term socioeconomic disability. Analysis of Cases Forty patients underwent vena caval ligation for thromboembolic disease; 23 patients were seen at the Duke University Medical Center and 17 patients were treated at the Durham Veterans Administration Hospital. There were 26 male and 14 female patients in the group, and the

Twenty-seven deep fungal infections developed in 22 of 171 patients following renal transplantation. These infections included cryptococcosis (ten), nocardiosis (seven), candidiasis (four), aspergillosis (two), phycomycosis (two), chromomycosis (one), and subcutaneous infection withPhialophora gougeroti(one). Twelve infections occurred in living-related and ten in cadaveric recipients. Nineteen of the 22 patients were male. Infections occurred from 0 to 61 months after transplantation. Complicating nonfungal infections were present concomitantly in 15 patients. Thirteen patients died, eight probably as a result of fungal infection. Appropriate diagnostic procedures yielded a diagnosis in 20 of 27 infections, and therapy was begun in 18 patients. Serologic, culture, and biopsy procedures useful in making rapid diagnoses are advocated in the hope of increasing survival.

It has been observed that "well put-together" people do not find the consideration of, nor events associated with, renal homotransplantation excessively stressful. One inadequate and one adequate patient did decompensate under the stress while on large doses of steroids. Education and socioeconomic status do not seem to exert an influence on motivation to participate. Motivation is based on consideration of kinship, duty, or altruism, or some or all of these. Spouses, while often unenthusiastic, rarely stand in the way of the donor's participation. All recipients and donors have been fully informed of the potential risks and benefits related to the procedures.