125I-8-L-arginine vasopressin binding to human mononuclear phagocytes.

The binding of vasopressin to human circulating blood cells was examined. Direct binding studies with preparations of single cell types indicated that the mononuclear phagocyte system is almost entirely responsible for binding of the hormone. Binding of 125I-8-L-arginine vasopressin (AVP) (40 pM) in the presence of excess unlabeled hormone was saturable (2.8 +/- 0.4 fmol/2 x 10(6) cells per ml), was linear with cell number, was dependent upon the concentration of the radioligand used, and was reversible. Binding equilibrium was achieved in 30--40 min at 22 degrees C. Scatchard analysis of binding at this time showed an apparent dissociation constant of 25 +/- 0.21 pM, providing an estimate of 640 +/- 80 sites/cell. Pretreatment of the cells with cytochalasin B, an agent that can block phagocytosis, did not modify radioligand binding, which indicates that 125I-AVP uptake by the cells is due to binding and not to endocytosis. Specificity of vasopressin-sensitive sites on mononuclear phagocytes was demonstrated with a series of vasopressin analogues with various degrees of antidiuretic potency, and with peptide hormones that bind to specific receptors on circulating blood cells but that lack antidiuretic activity. AVP (40 pM) elevated the intracellular level of cyclic AMP from 137 +/- 8.6 to 350 +/- 20.5 pmol/mg cell protein. The binding affinities of the various analogues were correlated with their ability to stimulate intracellular cyclic AMP synthesis (Lys8-vasopressin less than deamino(8-D-Arg)-vasopressin less than oxytocin).

Do serum C-reactive protein measurements help to discriminate episodes of renal dysfunction in patients after renal transplantation?

INTRODUCTION: This study investigated whether serial daily measurements of serum C-reactive protein (sCRP) could help differentiate episodes of transplant dysfunction due to rejection, infection, cyclosporine A (CsA) nephrotoxicity, or acute tubular necrosis (ATN) in renal-allograft recipients. MATERIALS AND METHODS: Morning serum was obtained daily from 134 patients during the first 30 days after renal transplantation. All episodes of graft dysfunction were recorded and differentiated with transplant biopsies. CRP concentrations were correlated with post-operative graft function and the various causes of graft dysfunction. RESULTS: All patients showed an increase in sCRP in response to surgery, with a maximum on day 2 after transplantation. The sCRP concentration was significantly higher in patients with delayed graft function (mean 61.50 microg/ml) than in patients with primary graft function (mean 38.01 microg/ml) (p=0.001). Bacterial infections other than asymptomatic bacteriuria (mean sCRP 33.98 microg/ml), interstitial graft rejection (mean sCRP 16.43 microg/ml), and ATN (mean sCRP 30.50 microg/ml) were accompanied by significant increases in sCRP compared with uneventful courses. sCRP was unchanged in the presence of viral infections or CsA toxicity. CONCLUSION: Serial sCRP measurements help to identify renal-transplant dysfunction of different origins. However, rejection, infection and ATN show similar patterns of sCRP increase. Thus, sCRP is unable to discriminate the causes of renal-graft dysfunction. Biopsy remains the gold standard for the differential diagnosis of renal-allograft dysfunction.

Problem cases in renovascular hypertension.

The clinical course and response to therapy of 16 patients with various complex forms of renovascular hypertension were investigated. Reconstructive surgery and/or transluminal dilatation was either ineffective (n = 5) or could not be performed for technical reasons (n = 11). The group contained 7 patients with multilocular fibromuscular disease involving both renal arteries, two cases with multiple arteriosclerotic vascular occlusions, 3 patients with branch renal artery aneurysms, 3 with renal artery stenosis in a solitary kidney and one patient with renal artery stenosis and contraction of the contralateral kidney due to a non-vascular cause. With antihypertensive treatment, particularly with the angiotensin converting enzyme inhibitor captopril (n = 7), blood pressure could be reduced from 214 +/- 40/124 +/- 23 mm Hg to 145 +/- 23/88 +/- 9 mm Hg (P less than 0.001). In 11 of the 16 patients (69%) the values decreased to less than 160/95 mm Hg. These results suggest that, in complex forms of renovascular hypertension, antihypertensive treatment may be a potent therapeutic alternative if surgery and/or transluminal dilatation can not be performed or seem to have too high a risk.

Hemofiltration in myoglobinuric acute renal failure.

The frequency of myoglobinuric renal failure is estimated between 8 and 20%. Despite early onset of therapy often the use of renal substitution by hemodialysis or hemofiltration is required. This study of the clinical course of nine patients with myoglobinuric acute renal failure reveals continuous arterio-venous hemofiltration (CAVH) to have an effective clearance for myoglobin. Thus, the time until recovery of renal function as well as the frequency of secondary complications in rhabdomyolysis induced acute renal failure can be distinctly reduced.

[Diagnosis of graft rejection]. / Diagnostik der Transplantatabstossung.

The topic of renal transplant rejection diagnosis is reviewed. The immunological and morphological findings and the clinical presentation of hyperacute, acute and chronic rejection are described. The indications for, and the value and limitations of diagnostic techniques such as core biopsy, fine-needle aspiration cytology, duplex Doppler sonography and immunological findings are analyzed. Early diagnosis and treatment are regarded as the central aim to prevent graft loss through rejection.

[Occurrence of lymphoceles after allogeneic kidney transplantation and their therapy]. / Untersuchung zum Auftreten von Lymphozelen nach allogener Nierentransplantation und deren Therapie.

We conducted a prospective evaluation of 301 consecutive renal transplants to define the prevalence and therapy of lymphoceles following renal transplantation. Using a management scheme, we identified in 52 patients (17.3%) perirenal fluid collections. Using this management scheme, we treated 47/52 patients conservatively. Only 5 (1.7%) patients required internal marsupialization. We conclude that groin lympho cysts after renal transplantation can be successfully treated with conservative methods.

[Urologic complications after kidney transplantation. Experiences in a center with 539 recipients]. / Urologische Komplikationen nach Nierentransplantation. Erfahrungen eines Zentrums bei 539 konsekutiven Rezipienten.

A total of 539 renal transplantations were performed at the Department of Urology of the University Hospital of Hamburg between 1984 and 1991. 132 (24.5%) patients developed urological complications (by definition, complications occurring as a result of the operative procedure). In 31 cases the transplants had to be removed secondary to urological complications, and 4 patients died of such complications (mortality 0.7%, lethality 3.0%). Urinary tract infections occurred in 13.2% of all patients during the first postoperative year and were by far the most frequent complication, followed by haematomas, which occurred in 9.6%. The incidence of urinary tract and wound infections was significantly reduced during the 8-year period studied by improving antibiotic prophylaxis and adopting a strategy of early removal of indwelling catheters (P < 0.05). Stenting the ureteroneocystostomy with a double-J stent instead of an external ureteral catheter resulted in a definite decrease in the incidence of ureteral leaks (P < 0.05). Continuous control of operative results and efforts to improve operative and perioperative strategies make it possible to reduce the incidence of urological complications in renal transplantation and thus result in an improved graft function and patient survival.

[Femoral arteriovenous fistula and transplant malfunction after allogeneic kidney transplantation. A case report]. / Femorale arteriovenöse Fistel und Transplantatfunktionsstörung nach allogener Nierentransplantation. Ein Fallbericht.

This case report deals with the clinical history of a 52-year-old woman who suffered from delayed graft function and ischaemic pain after a technically successful renal transplantation. The past history of the patient revealed that coronary catheters had repeatedly been used for investigation and treatment of myocardial infarctions. The clinical investigation reported here revealed a typical auscultatory result with an arteriovenous (AV) fistula in the right upper limb. After performing a digital arterial angiography, an AV fistula between the femoral artery and vein was demonstrated. Operative occlusion of the fistula increased the perfusion of the kidney graft and the right limb. The patient recovered without wound infection and could leave the hospital with the transplanted kidney functioning well. This case report demonstrates that persistence of AV fistulas after angiographic investigations is rare. Operative occlusion of these lesions should be performed before kidney transplantation to avoid steal phenomena and disturbed would healing.

[Perioperative incidence of transfusions after allogenic kidney transplantation]. / Perioperative Transfusionshäufigkeit nach allogener Nierentransplantation.

The requirement of blood transfusions was evaluated in a two compartment (retrospective/prospective) study in our renal transplantation program. Between July 1st, 1993 and December 31st, 1994 (observation period 1) we retrospectively investigated 110 patients with end stage renal disease and anemia undergoing kidney transplantation. Between January 1st, 1995 and December 31st, 1996 (observation period II) the requirement of blood transfusions was followed prospectively in 134 patients after allogenic renal transplantation. The amount of blood drawn for preoperative diagnostic investigations was in observation period 1 significantly higher (280 ml) than in observation period II (150 ml) (p = 0.02). For postoperative diagnostic tests in observation period II significantly less blood (240 ml) was needed than in observation period 1 (510 ml) (p = 0.01). The intraoperative blood loss was similar in both periods (170 ml vs. 190 ml; p = 0.6). The need for closer graft observation was the reason for significantly increased amount of blood transfusions in patients with delayed graft function. The number of blood transfusions was significant lower in patients with primary graft function (p = 0.0001). There was no correlation between blood transfusions and the use of ATG/OKT3, surgical complications and reoperations. With an improved management of blood drawing for diagnostic tests after allogenic kidney transplantation the number of perioperative blood transfusions can be reduced significantly.

[Cytomegalovirus diseases following allogenic kidney transplantation]. / Zytomegalievirus-(CMV-)Erkrankungen nach allogener Nierentransplantation.

Lymphotrophic virus infections, especially when they are caused by the cytomegalovirus, are severe complications after allogenic organ transplantation. First infections are mainly caused by donation of CMV-positive organs to CMV negative recipients. The regular incubation time of 30 to 40 days can be significantly shorter after therapeutic application with high dose prednisone or mono/polyclonal antibodies for treatment of rejection. The spectrum of clinical signs of the CMV-disease after organ transplantation can range between serological alterations and the lethal CMV-syndrome. The early recognition of virus-dependent clinical symptoms and the establishment of the diagnosis are the first conditions for the treatment, consisting in reduction of the immunosuppressive medication and application of ganciclovir, a CMV-specific virusstatic agent. The prophylactic application of CMV-hyperimmunoglobulin is discussed controversially. A very important aspect of CMV-disease in the long-term follow-up is the influence of this virus infection on the development of chronic organ rejection, which could be demonstrated in animal studies by application of the Marek virus and which was seen in pathomorphological samples of transplant biopsies. Future diagnostic and therapeutic strategies, which aim at the prolongation of the patient's survival and the transplant function have to consider the influence of virus infections as a severe risk-factor, as the transplantation of CMV-negative organs to CMV-negative recipients is more the exception than the rule.

[Rare variants and unusual course of Cushing's syndrome]. / Seltene Varianten und Verlaufsformen des Cushing-Syndroms.

Cushing's syndrome is a rarely observed disease with a poor prognosis when not treated appropriately. Knowledge of clinical features of the different forms of the disease together with a specific and subtle method of cortisol detection is indispensable for an early out-patient diagnostic program. In this study the characteristic features of the rare benign and malignant forms of Cushing's syndrome are presented in typical case-reports. As it has been proven in clinical experience, the necessary diagnostic measures for clarification of the syndrome consists of only few methods reliable concerning their diagnostic validity. The success of any curative treatment of the benign forms or any palliative measure of the malignant forms essentially depends on early diagnosis and differentiation of the various appearances of Cushing's disease.