Effects of cyclosporin A and low dosages of steroid on posttransplantation diabetes in kidney transplant recipients.

OBJECTIVE: To investigate the adverse effects of cyclosporin A (CsA) on pancreatic beta-cell function in kidney transplant recipients. RESEARCH DESIGN AND METHODS: The study consisted of 73 patients without a history of diabetes mellitus who had undergone kidney transplantation in our clinic. RESULTS: We experienced a higher incidence of posttransplantation diabetes mellitus (PTDM) in patients receiving CsA and low dosages of methylprednisolone (6/20, 30%, P less than 0.05) than in patients receiving conventional therapy of azathioprine methylprednisolone (4/53, 7.5%) since the introduction of CsA. In all 6 patients in the CsA-treated group, PTDM occurred within 3 mo after transplantation. The CsA level during the initial 3 mo posttransplant was significantly higher in diabetic than nondiabetic subjects, and the highest CsA level was observed shortly (1 mo) before the development of PTDM. After an average of 71 days of insulin therapy, there was complete remission of PTDM in 5 of 6 diabetic patients, with a corresponding decrease in CsA level. For the patients who were in remission for greater than 1 yr, a significant improvement of glucose intolerance was observed in association with a significantly higher insulin response to oral glucose load; however, their glycemic profile still showed a significantly higher plasma glucose concentration and a prolonged continuous elevation without initial peak of the insulin-response curve in contrast to the normal pattern found in nondiabetic subjects in the CsA-treated group. CONCLUSIONS: This study suggests that CsA in combination with low dosages of steroid may have adverse effects on glucose metabolism, which may lead to effects similar to those in non-insulin-dependent diabetes mellitus.

Outcome of surgery in cystic renal cell carcinoma.

OBJECTIVES: To review cases of cystic renal cell carcinoma treated surgically at our institution and define their clinical and histopathologic features. METHODS: Between 1986 and 1998, 21 patients with cystic renal cell carcinoma were treated surgically. Cystic renal cell carcinoma was categorized using Hartman's classification. RESULTS: Histopathologic examination demonstrated cystic necrosis in 11 patients, multilocular cystic renal cell carcinoma in 9, and unilocular cystic renal cell carcinoma in 1 patient. Tumors were incidentally found during an evaluation of unrelated disease or a general health checkup in 14 patients (67%). The mean tumor size was 5.6 cm (range 0.5 to 12) for cystic necrosis and 5.4 cm (range 2 to 9) for multilocular cystic renal cell carcinoma. All 9 cases of multilocular cystic renal cell carcinoma were of the clear cell type and tumor grade 1. The mean follow-up period was 65 months (range 9 to 141). The 5-year disease-specific survival rates for multilocular cystic renal cell carcinoma and cystic necrosis were 100% and 80%, respectively. CONCLUSIONS: The prognosis for patients with cystic renal cell carcinoma is better than that for patients with solid tumors. In particular, the prognosis of multilocular cystic renal cell carcinoma is excellent. Multilocular cystic renal cell carcinoma represents a distinct subtype of renal cell carcinoma that can be completely cured by surgery.

Subcutaneous administration of interferon alpha and gamma in patients with metastatic renal cell carcinoma.

BACKGROUND: Renal cell carcinoma (RCC) is relatively resistant to both chemotherapy and radiotherapy. Response and survival of treatment with Interferon-alpha (IFN-alpha) and Interferon-gamma (IFN-gamma) were evaluated in patients with metastatic RCC. PATIENTS AND METHODS: Thirty-one patients with confirmed RCC were included in this study. Fifteen of 31 patients received injection of IFN-alpha and IFN-gamma three times a week. IFN-gamma was infused subcutaneously by microinfusion pump. Sixteen received IFN-alpha alone more than three times a week. RESULTS: The overall response rate was 20.0% in the IFN-alpha and IFN-gamma group, and 12.5% in the IFN-alpha alone group. Long lasting stabilization of the disease (more than; 12 months) was seen in 92.3% of CR, PR or SD in the IFN-alpha and IFN-gamma group, as compared with 71.4% in the IFN-alpha alone group. Both groups differed significantly in survival rate from the first treatment with IFN (p < 0.05). CONCLUSIONS: A long lasting stabilization of the disease can be expected in patients who were treated with our regimen of IFN-alpha and IFN-gamma.

Renal cell carcinoma metastatic to the skin.

BACKGROUND: Cutaneous metastases from renal cell carcinoma are rarely diagnosed during life. We reviewed the cases of our institute and from the Japanese literature and analyzed them to define the clinical features. PATIENTS AND METHODS: Six patients with cutaneous metastases from renal cell carcinoma were treated in our institute. Clinical data and follow-up information of these patients were reviewed. RESULTS: The skin metastatic lesions were found before the renal lesion was discovered in one case and they were found after the diagnosis had been established in 5. Four patients presented with solitary cutaneous metastasis at the time of diagnosis of the skin metastatic lesion. Five patients had other sites of metastases such as the lung, liver and bone at the time of diagnosis of cutaneous metastases. Five patients died of renal cell carcinoma at mean 23.8 months after presenting with cutaneous metastases. CONCLUSION: Our 6 cases bring the total reported in the Japanese literature to 75 cases. The results of these 75 cases revealed that the duration from the time of diagnosis of renal cell carcinoma to detection of the cutaneous metastasis was relatively long but the prognosis of patients with these metastatic skin lesions was poor. Cutaneous metastases from renal cell carcinoma were regarded as a late manifestation of the disease.

Captopril-associated granulocytopenia in hypertension after renal transplantation.

A living related kidney transplant recipient with normal renal functioning and hypertension secondary to renal artery stenosis was treated with captopril and developed reversible granulocytopenia. Complications caused by captopril, an angiotensin converting enzyme inhibitor, have been reported previously in hypertensive patients with systemic lupus erythematosus or with renal artery stenosis after renal transplantation. It is recommended that this drug be used with caution in this setting.

Kidney transplantation from non-heart-beating donors: analysis of organ procurement and outcome.

INTRODUCTION: Most donors in Japan have been non-heart-beating donors (NHBD), so-called "marginal donors." In Western countries kidney transplants from NHBD have also been increasing. We analyzed 120 kidneys harvested from NHBD with regard to organ procurement, renal function, graft survival, and the donor factors that affected graft survival. METHODS: Donors were moved into the operating room after cardiac arrest. A double-balloon catheter was inserted into the abdominal aorta via laparotomy. In situ cooling by Euro-Collins solution was started at 500 mL/min. We did not performed cannulation into the femoral artery or vein prior to cardiac arrest. RESULTS: Warm ischemia time (WIT) was 18.6 minutes. Among 108 kidneys (90%) used for transplantation, 102 kidneys functioned. There were no cases of bilateral nonfunctioning kidneys. The delayed graft function (DGF) rate was 86%; however, the death-censored graft survival was 80.0% at 5 years and 62.9% at 10 years. Kidneys implanted after more than 24 hours of total ischemia time required a significantly longer period of hemodialysis. Donor risk factors that affected graft survival included WIT >/= 20 minutes, donor age >/= 50 years, and serum creatinine level at admission > 1.0 mg/dL. CONCLUSIONS: Organ procurement without cannulation prior to cardiac arrest entailed a long WIT and a high DGF rate. However, the graft survival was good. It has been necessary to use grafts from NHBD despite the inherent risk factors. It is important to reduce kidney damage both at the organ procurement and during the posttransplant management.

Multiloculated renal cell carcinoma.

Multiloculated renal cell carcinoma and multilocular renal cyst with renal cell carcinoma are uncommon diseases. We report on 2 cases of multiloculated renal cell carcinoma. To our knowledge 16 cases of multiloculated renal cell carcinoma and multilocular renal cyst with renal cell carcinoma have been previously described in detail. The authors review the literature and discuss the aetiology and diagnosis of the disease.

[Long-term experience with renal transplantation in systemic amyloidosis: a case report].

Renal transplantation was performed on a 39-year old woman with secondary amyloidosis due to rheumatoid arthritis. She remains alive and renal function has been maintained satistfactorily with the exception of proteinuria ten years after transplantation. Recent renal biopsy showed no amyloid recurrence, but the presence of chronic rejection reaction and mild cyclosporin arteriolopathy. Symptoms related to systemic amyloidosis and rheumatoid arthritis improved after transplantation. Renal transplantation is the recommended therapy for the type AA systemic amyloidosis. This is the second report of long-term experience with renal transplantation in systemic amyloidosis in Japan.

[Clinical evaluation of renal angiomyolipoma].

Between April 1980 and December 1999, 23 kidneys in 20 patients were diagnosed as having renal angiomyolipoma at our institution. The patients were 6 males and 14 females aged 24 to 79 years, with a mean age of 55.4 years. Two patients had associated tuberous sclerosis and 3 had bilateral disease. Of all patients the main clinical symptoms were pain (45%) and palpable mass (40%); 5 patients (25%) had asymptomatic lesions. The size of the tumor ranged from 1.3 to 24 cm (mean 7.7 cm). Treatment consisted of nephrectomy in 9 patients, partial nephrectomy in 6 and selective embolization in one. Pre-operative diagnosis was renal cell carcinoma in 5 of the 9 patients who underwent nephrectomy. Six patients with 7 diseased kidneys were followed radiologically. One patient underwent percutaneous biopsy to confirm the diagnosis. We suggest that nephron-sparing surgery for patients with renal angiomyolipoma should be the first step if tumor size is 4 cm < or = or increasing rapidly. Selective embolization is also a useful method. However, we need long-term follow-up to evaluate the effectiveness of embolization.

[Studies on prophylaxis and therapy of pivmecillinam against post-prostatectomy urinary tract infection].

Patients received pivmecillinam (PMPC) after prophylactic use of various antimicrobial chemotherapeutic agents following prostatectomy, and their clinical responses were assessed for effectiveness in the treatment and prevention of postoperative infection. The data were also analyzed to explore the relationship between bacterial isolates obtained during the postoperative course and the antimicrobial agents administered prophylactically against postoperative infection. Therapeutic effect of PMPC: Treatment of postoperative infections with PMPC was effective in 36 (53.7%) out of 67 patients who had undergone prostatectomy. Prophylactic effect of PMPC: The use of PMPC provided effective prevention of infection in 22 (64.7%) out of 34 patients from whom no bacterial pathogen had been isolated before postoperative antimicrobial chemotherapy. Therapeutic responses to PMPC, compared between different types of operative procedure: There was little or no difference in therapeutic effectiveness of PMPC against postoperative infection when compared between two types of operative procedure, transurethral prostatectomy and subcapsular removal of the prostate. Incidence and types of bacterial isolates following prophylactic chemotherapy with various agents after prostatectomy: Possibly because cephapirin (CEPR) and ticarcillin (TIPC) were mainly administered, alone or in combination, for prophylaxis against postoperative infection, Serratia and Pseudomonas were most frequently isolated. The findings offer suggestions as to the appropriate combination of antimicrobial agents to be used for prophylactic purposes. Effectiveness of PMPC in the presence or absence of a preoperative indwelling urethral catheter: The use of PMPC was more effective both in the treatment and prevention of postoperative infection in cases without preoperative indwelling urethral catheterization than in those with it.

[Evaluation of bone metastases from renal cell carcinoma].

Forty-two cases of bone metastasis from renal cell carcinoma were examined. Thirty of the cases had bone metastases at the time of renal cell carcinoma. Bone metastasis appeared after treatment of the primary site in 12 cases. Fifteen cases had only bone metastasis and another 27 had metastasis in multiple organs. The total cause-specific survival curve of these patients was 10% at 5 years. All patients with bone metastases died of cancer within 5 years after the bone metastases had developed. There was no significant difference in the survival rate between patients with bone metastases and patients with lung metastases. We investigated the prognostic value of laboratory studies in bone metastases of renal cell carcinoma. However, no significant markers were detected for bone metastases. The 6 patients were treated with decompressed laminectomy (2), wide resection (3) and excision of the metastatic lesions (3). The quality of life was improved in all the patients although they died of cancer.

[Clinical examination and therapies of hydronephrosis after radical hysterectomy].

We investigated postoperative hydronephrosis in 50 patients (100 ureter) undergoing radical hysterectomy for uterine cervical cancer from Jan. 1989 to Dec. 1991 at Department of Obstetrics and Gynecology in Nagasaki University Hospital. The incidence of hydronephrosis was 68.1% of patients, and hydronephrosis was seen significantly more frequently and was of a higher grade on the right kidney than the left. After one year, hydronephrosis disappeared in 59.1% of patients (65.1% of right kidney, 88.2% of left kidney), and only 2 of 93 kidney have worsened. In cases without hydronephrosis, hydronephrosis developed in only 3 of 31 kidney after one year due to local recurrence or nodule metastasis of the original disease. We compared therapeutic effects of 3 methods (ureteral stent, PNS, no treatment). But there was no significant difference between these methods, we could not determine which was the best treatment. And we observed that indwelling ureteral stent might interrupt spontaneous healing of ureter. Radiotherapy didn't significant influence hydronephrosis after radical hysterectomy; Therefore, we suggest that, in patients with hydronephrosis without other severe urological complications after radical hysterectomy, clinical course should be observed for at least one year, first and them some treatments should be applied if cases worsen gradually than before.

[Usefulness of renal CT scan for analysis of nutcracker phenomenon].

Among 24 patients with confirmed left renal bleeding, 11 were diagnosed of having nutcracker phenomenon (NP) on the basis of the results of renal venography and pull-back pressure from the left renal vein to the inferior vena cava. Renal CT scan was performed for these 11 patients, and its usefulness as a means of diagnostic analysis was studied. The following results were obtained. 1. The left kidney was scanned at 5-mm intervals. The mean distance between the anterior surface of the abdominal aorta (Ao) and the posterior surface of the superior mesenteric artery (SMA) was 4.5 +/- 0.6 mm in the NP group, while it was 13.9 +/- 6.4 mm in the control group (p < 0.01). 2. Regarding the morphology of the left renal vein (LRV), tapering dilatation, i.e., funnel-like dilatation, from the left side of Ao was seen in the NP group. In the control group, the left renal vein showed a club-like shape continuing to the inferior vena cava and showed no dilatation. 3. Vascular structures indicative of collateral vessels were observed around the LRV in the NP group. If renal CT scan is performed at 5-mm intervals, the following CT finding are thought to be indicative of the nutcracker phenomenon; (1) a distance of 5 mm or less between Ao and SMA and (2) tapered dilatation of the LRV. This study suggests that renal CT scan is useful for diagnostic analysis of the nutcracker phenomenon.

Acute hemorrhagic cystitis caused by adenovirus following renal transplantation: review of the literature.

We report on 4 male patients with acute hemorrhagic cystitis caused by adenovirus following renal transplantation. These patients showed symptoms of gross hematuria, urinary frequency, burning urination and fever. Adenovirus was isolated in all patients and 3 were positive for serotype 11. Complement-fixing antibody was positive for adenovirus in all cases. Acute hemorrhagic cystitis caused by adenovirus was self-limiting and reduction of immunosuppression was not required for its resolution. Clinical presentation of these patients is described and the literature is reviewed.

Acute hemorrhagic cystitis caused by adenovirus type 11 after renal transplantation.

A case of acute hemorrhagic cystitis caused by adenovirus type 11, which occurred in an allograft recipient 6 months after a living-related renal transplantation, is described. The patient lacked a neutralizing antibody to adenovirus type 11 before transplantation. Adenovirus type 11 was isolated from his urine and he developed a neutralizing and complement-fixing antibody to this virus. Although adenovirus type 11 isolates had been obtained from 2 of 18 renal allograft recipients, only 1 patient suffered acute hemorrhagic cystitis. Adenovirus type 11 may play a role in acute hemorrhagic cystitis in renal allograft recipients during immunosuppressive therapy.