The use of drug-eluting stents in the management of transplant renal artery stenosis.

Transplant renal artery stenosis (TRAS) is a common occurrence following kidney transplantation with an incidence rate ranging from 6% to 23%. A single-center retrospective study was conducted to examine the use of drug-eluting stents (DES) in eligible patients with hemodynamically significant TRAS. Between March 2008 and January 2011, 12 patients were diagnosed with TRAS with reference vessel diameter measuring <5 mm and underwent endovascular intervention (EVI) with DES placement. TRAS was detected within the first year posttransplantation in a majority of these patients (83%) and manifested as hypertension (100%), allograft dysfunction (100%) and edema (58%). Procedural success rate was 100%. Patients were followed for a mean period of 16 ± 10 months. Blood pressure improved from a mean of 156/82 to 138/73 mmHg at the end of the follow-up period. In 11/12 patients, serum creatinine improved from 3.1 ± 1.3 mg/dL to 2.3 ± 0.5 mg/dL at the end of the follow-up period. TRAS of early onset is readily amenable to EVI with stent placement resulting in improvement in blood pressure control and allograft function.

Invasive aspergillosis in a renal transplant recipient successfully treated with interferon-gamma.

Invasive aspergillosis is a serious complication of solid organ transplantation. An early diagnosis is hampered by the lack of reliable serum markers and, even if appropriately diagnosed and treated with current antifungal agents, has a high mortality rate. We report a case of invasive pulmonary and cerebral aspergillosis in a renal transplant patient treated with IFN-γ in conjunction with combination anti-fungal therapy for six weeks in whom complete resolution of the fungal infection was achieved. Renal function remained intact throughout the treatment period. Surveillance CT scans of the chest and head showed resolution of prior disease but revealed a new left upper lobe mass four months after completion of treatment with IFN-γ. Biopsy of the lesion was positive for primary lung adenocarcinoma, for which she underwent left upper lobe resection. The pathology report confirmed clear surgical margins and lymph nodes and no evidence of fungal hyphae. IFN-γ should be considered early in the management of invasive aspergillosis in renal transplant patients. To date, allograft rejection has not been encountered.

The efficacy of norfloxacin in the treatment of chronic bacterial prostatitis refractory to trimethoprim-sulfamethoxazole and/or carbenicillin.

We treated 15 men who had chronic bacterial prostatitis refractory to trimethoprim-sulfamethoxazole and/or carbenicillin with 400 mg. norfloxacin twice daily for 28 days. All pathogens were susceptible to norfloxacin and absent in prostatic fluid cultures obtained during therapy. One patient had negative post-therapy prostatic fluid cultures but was lost to followup at 1 month. Of the 14 patients followed for at least 6 months 9 (64%) were cured of the original infection, including 6 who have remained uninfected and have had negative prostatic secretion and urine cultures for at least 2 years (1), 1 year (2) or 6 months (3). In 3 patients urinary tract infections recurred with new pathogens at 6, 560 and 820 days after post-therapy negative prostatic fluid cultures. Bacterial prostatitis with the original pathogen recurred in 5 patients within 2 months of completing therapy. The bacteria remained susceptible to norfloxacin but could not be eradicated with 30 to 90 days of additional norfloxacin therapy. Cures were achieved in 9 of 12 patients with Escherichia coli, none of 2 with Pseudomonas prostatitis and 3 of 5 with prostatic calculi. No patient experienced significant adverse effects. The data suggest that norfloxacin is effective and safe for the treatment of refractory chronic bacterial prostatitis.

Solitary metachronous contralateral adrenal metastasis from renal cell carcinoma.

Malignant involvement of the contralateral adrenal gland in cases of renal cell carcinoma is extremely rare. We report a case of solitary metachronous contralateral adrenal metastasis occurring 7.5 years after radical nephrectomy. The metastasis was treated with adrenalectomy and steroid replacement. Thirty months later, the patient remained without evidence of disease. This very rare presentation can prove to be a diagnostic challenge. Appropriate aggressive surgical treatment is warranted.

Evidence for a non-androgenic role of testis and epididymis in androgen-supported growth of the rat ventral prostate.

A widely held view is that the role of testis in prostatic growth is through its ability to secrete androgen. Our earlier observation suggested a non-androgenic role for the testis, and perhaps the epididymis, in promoting growth of the ventral prostate in rats. The present study was conducted to evaluate the separate role of the testis and the epididymis in this phenomenon. In the first study, increasing quantities of silastic tubing filled with crystalline testosterone were implanted into adult Sprague-Dawley rats at the time of bilateral epididymo-orchiectomy or sham-operation. Twenty-eight days later, growth of the ventral prostate, as determined by fresh weight, DNA, and protein content, was significantly greater in sham-operated rats than in those receiving combined epididymo-orchiectomy, confirming our previous observation using dihydrotestosterone. In the second and third studies, rats were subjected to selective surgical procedures to evaluate the independent role of the testis and the epididymis. At the same time, 12 cm silastic tubing filled with testosterone or dihydrotestosterone were implanted subcutaneously into each of these animals for 28 days. Results indicated that the ventral prostate was significantly smaller in rats receiving the combined epididymo-orchiectomy than that of sham-operated controls. Simple orchiectomy or simple epididymectomy resulted in an increased weight of the ventral prostate between the two values obtained from the above two groups. Ligation of either the efferent duct or the vas deferens yielded ventral prostatic weights comparable to the androgen-treated, sham-operated controls. These results indicated that in order to achieve a maximal effect on androgen-supported growth of the ventral prostate, the presence of both the testis and the epididymis is required.

Kidney allocation under the UNOS point system: an update.

1. The 1,480 patients awaiting cadaveric renal transplants at 14 Southern California transplant centers as of December 3, 1992, were compared with patients transplanted using a point system for one kidney and a hospital-based allocation for the second, or the current system allocating all locally procured kidneys by the point system with regard to several demographic parameters. 2. Of 1,472 waiting patients with sensitization data, 8.5% were broadly sensitized (> 80% PRA). Of the 737 kidneys allocated by the point system, 7% went to broadly sensitized patients, compared with 3% of 438 kidneys allocated by the hospitals (p < 0.001). 3. Of 1,470 waiting patients with information available, 23% were awaiting a repeat transplant. Under the point system, 18% of kidneys were used for repeat transplants compared with 9% of hospital-allocated kidneys (p < 0.001). 4. Of 1,434 waiting patients where the time waiting was available, 26% had waited 1-2 years, 12% 2-3 years, and 6% more than 3 years. Under the point system, patients waiting longer received significantly more kidneys than those recently added to the list: 35% had waited 1-2 years, 21% 2-3 years and 14% more than 3 years (p < 0.001). Kidneys allocated by the hospitals were transplanted to patients in approximately the same proportions as the waiting list: 29% to those waiting 1-2 years, 10% 2-3 years, and 3% more than 3 years. 5. Racial distribution of recipients was not significantly different under either allocation system from that of the waiting list. Whites comprised 39% of waiting patients, the same as the population of Los Angeles County.(ABSTRACT TRUNCATED AT 250 WORDS)

Polycystic kidney disease: an unrecognized emerging infectious disease?

Polycystic kidney disease (PKD) is one of the most common genetic diseases in humans. We contend that it may be an emerging infectious disease and/or microbial toxicosis in a vulnerable human subpopulation. Use of a differential activation protocol for the Limulus amebocyte lysate (LAL) assay showed bacterial endotoxin and fungal (1-->3)-beta-D-glucans in cyst fluids from human kidneys with PKD. Fatty acid analysis of cyst fluid confirmed the presence of 3-hydroxy fatty acids characteristic of endotoxin. Tissue and cyst fluid from three PKD patients were examined for fungal components. Serologic tests showed Fusarium, Aspergillus, and Candida antigens. IgE, but not IgG, reactive with Fusarium and Candida were also detected in cyst fluid. Fungal DNA was detected in kidney tissue and cyst fluid from these three PKD patients, but not in healthy human kidney tissue. We examine the intertwined nature of the actions of endotoxin and fungal components, sphingolipid biology in PKD, the structure of PKD gene products, infections, and integrity of gut function to establish a mechanistic hypothesis for microbial provocation of human cystic disease. Proof of this hypothesis will require identification of the microbes and microbial components involved and multifaceted studies of PKD cell biology.

Endotoxin and nanobacteria in polycystic kidney disease.

BACKGROUND: Microbes have been suspected as provocateurs of polycystic kidney disease (PKD), but attempts to isolate viable organisms have failed. Bacterial endotoxin is the most often reported microbial product found in PKD fluids. We assessed potential microbial origins of endotoxin in cyst fluids from 13 PKD patients and urines of PKD and control individuals. METHODS: Fluids were probed for endotoxin and nanobacteria, a new bacterium, by the differential Limulus Amebocyte Lysate assay (dLAL), genus-specific antilipopolysaccharide (LPS) antibodies, monoclonal antibodies to nanobacteria, and hyperimmune serum to Bartonella henselae (HS-Bh). Selected specimens were also assessed by transmission electron microscopy (TEM) and nanobacterial culture methods. RESULTS: LPS or its antigenic metabolites were found in more than 75% of cyst fluids tested. Nanobacteria were cultured from 11 of 13 PKD kidneys, visualized in 8 of 8 kidneys by TEM, and immunodetected in all 13 PKD kidneys. By immunodetection, nanobacterial antigens were found in urine from 7 of 7 PKD males, 1 of 7 PKD females, 3 of 10 normal males, and 1 of 10 normal females. "Nanobacterium sanguineum" was dLAL positive and cross-reactive with antichlamydial LPS and HS-Bh. Some cyst fluids were also positive for LPS antigens from Escherichia coli, Bacteroides fragilis and/or Chlamydia, and HS-Bh, as were liver cyst fluids from one patient. Tetracycline and citrate inhibited nanobacterial growth in vitro. CONCLUSION: Nanobacteria or its antigens were present in PKD kidney, liver, and urine. The identification of candidate microbial pathogens is the first step in ascertaining their contribution, if any, to human disease.