Histologic diagnosis of rejection by using cystoscopically directed needle biopsy specimens from dysfunctional pancreatoduodenal allografts with exocrine drainage into the bladder.

To determine the histologic features of rejection and to identify nonrejection causes of human pancreatic allograft dysfunction, we analyzed 31 needle biopsy specimens (17 pancreatic, 14 duodenal) obtained under cystoscopic direction from 15 dysfunctional pancreatoduodenal allografts with exocrine drainage into the bladder. Eight allografts undergoing rejection showed the most common histologic features of rejection to be diffuse mixed inflammatory infiltrates of pancreatic acinar tissue and duodenum wall. Diffuse infiltration of pancreatic acinar tissue by neutrophils was the earliest histologic change in rejection. Seven dysfunctional allografts not undergoing rejection ("nonrejection") showed a normal pancreas or various changes including acinar dilation with inspissation of secretions, fibrosis, cytomegalovirus inclusions, and enzymatic necrosis. The histologic changes in the duodenum paralleled those in the pancreas in both rejection and nonrejection allografts. We conclude that the histologic features of rejection in pancreatoduodenal allografts are distinctive. The changes seen in biopsy specimens accurately reflect the state of the graft and can be used to diagnose rejection and to identify other causes of graft dysfunction. Biopsy samples from the duodenum as well as the pancreas are diagnostically useful. The biopsy findings can be used to guide the clinical management of rejection and in the development of other noninvasive tests for rejection.

Morbidity of pancreas transplantation during cadaveric renal transplantation.

Simultaneous transplantation of the pancreas is an option for diabetic patients undergoing kidney transplantation to attempt to halt progression of diabetic complications, but the additional risk imposed by the procedure is unclear. Our aim was to determine the morbidity attributable to pancreas transplantation during simultaneous pancreas and kidney transplantation. We compared the first posttransplant year of 18 consecutive recipients of combined pancreas and kidney transplantation to 18 consecutive recipients of kidney transplantation alone. All patients received cadaver donor allografts between 1986 and 1989, and had type I diabetes mellitus with chronic renal failure. There were no differences in patient survival (94% both groups) or satisfactory renal allograft function (89% pancreas/kidney group, 83% kidney group) up to 18 months after transplantation. Eighty-eight percent of pancreas allografts were functioning satisfactorily at 18 months. There was a mean (+/- SD) of 1.5 +/- 1.0 acute rejection episodes per patient for the pancreas/kidney group compared to 0.8 +/- 6 for the kidney-only group (P less than 0.02). Cytomegalovirus infection and wound complications were each encountered more often after pancreas/kidney transplantation than kidney transplantation alone, and together with rejection accounted for a difference in days of hospitalization during the first year (71 +/- 34 vs. 27 +/- 13, P less than 0.001). We conclude that simultaneous pancreas transplantation during cadaver donor kidney transplantation accounted for more frequent rejection episodes, CMV infections, and wound complications. These complications resulted in more hospitalization for patients undergoing simultaneous pancreas/kidney transplantation than kidney transplantation alone.

Differential diagnosis of hypoamylasuria in pancreas allograft recipients with urinary exocrine drainage.

We have studied the histopathologic correlates of a significantly decreased urinary amylase excretion rate (UAER) to determine its reliability in predicting the presence of cellular rejection within pancreas allografts drained via a duodenocystostomy. Significant hypoamylasuria in pancreas allograft recipients was defined as a diminution of greater than 50% in UAER sustained for greater than 36 hr and not associated with a decrease in serum amylase activity. We observed 18 such episodes of hypoamylasuria in 13 of 18 patients receiving pancreas allografts. Pancreaticoduodenal material was obtained during 11 of these episodes, one attempt failed, and for the remaining 6 episodes we obtained 3 renal allograft biopsy specimens. Histopathologic examination of the 14 specimens revealed cellular rejection in 9 (64%), fibrosis in 2 (14%), enzymatic necrosis in 1 (7%), cytomegaloviral pancreatitis in 1 (7%), and no abnormal features in 1 (7%). During these 14 episodes, a genetically identical renal allograft was present for 11 and showed signs of dysfunction in 9; however, the pancreatic histologic features suggested rejection in only 7 of the 9. Thus even the combination of hypoamylasuria and renal dysfunction in recipients of genetically identical organs was not fully reliable in predicting pancreas allograft rejection. In addition, the interval between organ implantation and onset of hypoamylasuria did not predict the histologic diagnosis. As with other solid-organ allografts, biopsy is a useful adjuvant for determining patient management in the presence of organ dysfunction.

Current status of renal transplantation--1986.

During the course of 3 decades, and particularly during the past 5 years, clinical renal transplantation has improved to become a safe mode of therapy for end-stage renal disease. Currently, more than 95% 1-year survival can be expected, both in patients who receive allografts from living-related donors and in those who receive cadaver kidneys. One-year living-related donor graft survival is 98%, and 1-year cadaver graft survival is 87%. Cyclosporine has been an important adjunctive immunosuppressive agent not only because of improved results but also because it has shortened hospitalization time.

Treatment of renal cell carcinoma by in situ partial nephrectomy and extracorporeal operation with autotransplantation.

During a 10-year period, 33 patients underwent in situ enucleation, in situ partial nephrectomy, or an extracorporeal operation for low-grade (1 or 2), low-stage (I or II), bilateral or solitary renal cell carcinoma. Only one patient (3%) (who had undergone in situ partial nephrectomy) had local recurrence; the projected 5-year rates of nonprogression of disease and survival from death due to cancer only were 76% and 87%, respectively. A group of patients who were closely matched for grade and stage of renal cell cancer underwent traditional transabdominal radical nephrectomy during the same time interval and had rates of nonprogression and survival similar to those of the conservative surgical group. Thus, in selected patients with low-grade, low-stage renal cell cancer, conservative surgical treatment (that is, renal parenchyma-saving procedures) can produce favorable results without the side effects (such as renal failure) associated with ablative renal operations.

Spontaneous renal rupture during pregnancy.

Spontaneous rupture of the renal parenchyma or renal pelvis during pregnancy has been previously reported in 16 cases. In the case we describe in this report, the patient initially had right flank pain and nausea for 48 hours, which progressed to severe abdominal symptoms that necessitated exploratory laparotomy. Cystoscopic placement of a ureteral stent relieved the obstruction and allowed spontaneous healing of the renal pelvis. Dilatation of the urinary collecting system commonly occurs during pregnancy. Spontaneous rupture of the renal parenchyma or renal pelvis, however, is unusual and often associated with diseased kidneys. Our case is the 8th one of spontaneous rupture of the renal collecting system with no identifiable underlying pathologic condition and the 17th case of spontaneous renal rupture overall.

Pancreas transplantation at Mayo: II. Operative and perioperative management.

Better perioperative and operative management techniques have contributed to an improvement in the success rate of pancreas transplantation. Because of a shortage of donor organs, the criteria for acceptability of the allograft have been liberalized, and the development of techniques such as combined liver and pancreas procurement has increased allograft availability. Major advances have been made in organ preservation. Currently, pancreas allografts can routinely be stored for 18 to 24 hours. The technique of pancreaticoduodenal transplantation with a duodenocystostomy for the exocrine drainage is widely used. Experience with anesthetic and intensive-care unit management of these patients is accumulating. With the evolution of pancreas transplantation and with the help of the excellent transplant centers in our area, we developed a pancreas transplantation protocol and performed transplantation based on this protocol in 16 recipients at the Mayo Clinic from October 1987 through December 1988.

Hemosiderosis of urinary bladder.

We believe this is the first case of proved hemosiderosis of the bladder to be reported. The clinical presentation, radiographic findings, and cystoscopic appearance suggested a primary bladder neoplasm.

Renal plasmacytoma: Mayo Clinic experience and review of the literature.

Extramedullary plasmacytoma arising in the kidney is rare. Only 8 cases have been reported. Recently, we noted the ninth case, the second case seen at the Mayo Clinic. Clinically, the tumor mimics a renal cell carcinoma or a transitional cell carcinoma of the renal pelvis.

Intravesical condyloma acuminatum with progression to verrucous carcinoma.

Condyloma acuminatum is a common form of venereal disease. Most patients with condylomata acuminata suffer from only the local cosmetic and irritative effects of the lesions. Few patients have progression to aggressive, regionally distributed lesions that can be life-threatening. We describe a forty-three-year-old white woman who had a seventeen-year history of scleroderma with extravesical and intravesical condylomata acuminata. During two years of conservative management with transurethral excision, electrocoagulation, and intravesical chemotherapy, the disease progressed to involve the entire bladder and resulted in obstructive renal insufficiency that required anterior exenteration and urinary diversion. The natural history of the disease is described, and the relevant literature is reviewed.

Splenectomy in high-risk primary renal transplant recipients.

One hundred sixty-five high-risk patients who were either 50 years of age or older or had diabetes mellitus, or both underwent primary renal transplantation. One hundred eight had splenectomy and 57 did not. Graft and patient survival were analyzed in regard to whether splenectomy had been performed at all and whether it had been performed 30 days or more before transplantation, less than 30 days before, or at the time of transplantation. Also, the influence of age, diabetes, blood transfusions, blood type, donor type, HLA mismatch, pretransplantation dialysis, and percentage of performed antibodies were analyzed, as were complications and causes of death. Differences in patient survival were not significant in any one of these categories, although survival in the splenectomized group was generally better. The incidence of infection and sepsis was comparable in both groups and was responsible for death in 34 percent of the patients who underwent splenectomy compared with 22 percent of those who did not (no significant difference). Splenectomy improved cadaver donor renal allograft survival (p = 0.001) in the diabetic patients (p = 0.015) and in those 50 years of age or older (p = 0.026) but it did not improve survival in those who received living related donor kidneys. No significant differences were detectable in regard to the timing of splenectomy. The effect of splenectomy was significant in the patients who had not received transfusions (p = 0.003). It also improved survival in the transfused patients. Splenectomy in high-risk diabetic patients and patients 50 years of age or older does not seem to be associated with increased mortality.

Improving results in primary diabetic renal transplantation.

One hundred seventeen patients with renal failure resulting from insulin-dependent diabetes mellitus received primary renal allografts from June 1970 to April 1983. Factors significantly associated with improved graft and patient survival were LRD sources (in particular, HLA-identical) and splenectomy. Variables such as transfusions, age, sex, and the administration of ALG were not significantly associated with transplant outcome. However, survival of patients and grafts has improved in recent years and continues to compare favorably with hemodialysis results. Although splenectomy might be the most important variable responsible for the improvement of our recent results, the use of ALG for rejection episodes might have contributed substantially to the improvement. Early transplantation, not analyzed in this study, might prove to be the most significant variable in the outcome of transplantation in patients with diabetic renal failure.

Renal artery graft-to-duodenum fistula: unusual presentation of a recurrent flank abscess.

Perhaps the most devastating complication of a prosthetic vascular graft is the formation of an aortoenteric fistula. Most reports have dealt with fistulas between the aortic graft and the duodenum, although any revascularized vessel with prosthetic material can be the site of an enteric fistula. We report an unusual case in which a renal artery previously revascularized with a silk prosthetic graft developed a fistula to the duodenum 16 years later. Whether the prosthetic graft is in the aortic position or to a visceral vessel, when a fistula develops the only acceptable treatment is complete removal of the graft and revascularization with autogenous tissues, if necessary.

Malignancy in uremia: dialysis versus transplantation.

The incidence of cancer was compared in 499 dialysis patients and 121 renal transplant recipients. De novo malignancy developed in 15 patients on chronic dialysis (3 per cent) and in 6 transplant recipients (4.9 per cent), a significant increase over the expected number in the age-matched general population. There was no difference in the incidence of cancer in uremic patients on dialysis or after transplantation. A total of 10 dialysis patients (67 per cent) and 1 transplant patient (16 per cent) died of cancer. Neoplasms in the dialysis patients were the common types of mesenchymal tumors, while superficial skin cancers were seen more frequently in the transplant recipients. The differences in tumor types accounted for the higher mortality rate from cancer in the dialysis patients and may reflect different patterns of immunosuppression in these 2 patient populations.

The clinical spectrum of granulomatous prostatitis: a report of 200 cases.

Granulomatous prostatitis, reviewed in 200 tissue-diagnosed cases, occurred in 0.8 per cent of the benign inflammatory prostatic specimens. Often the disease followed a recent urinary tract infection (71 per cent) and was suspicious clinically for prostatic cancer (59 per cent). The diagnosis usually was made by needle biopsy or at transurethral prostatectomy (94 per cent). Most cases of granulomatous prostatitis were classified as nonspecific. The recently identified entity of post-transurethral resection granulomatous prostatitis was found in 49 patients. A proposed new category of granulomatous prostatitis that is secondary to systemic granulomatous diseases was documented in 6 patients. Most cases of granulomatous prostatitis resolved spontaneously and required no specific therapy.

Adaptation of existing cutaneous ureterostomy for urinary drainage after renal transplantation.

We adapted existing cutaneous ureterostomies for urinary drainage in 3 patients who underwent renal transplantation. Careful preoperative radiological evaluation of the ureteral anatomy and appropriate preoperative planning are necessary for such patients. The concentration of serum creatinine was 0.9, 1.3 and 1.5 mg. per dl. at 2 months, 3 years and 10 years, respectively, after transplantation. All 3 patients have had bacteriuria that necessitated therapy with chronic suppressive antibiotics but clinical pyelonephritis has not occurred.