Results of parathyroidectomy for autonomous hyperparathyroidism.

Autonomous hyperparathyroidism occurred in 15% of 152 patients maintained by long-term home dialysis during the past nine years. Twenty-two patients with elevated serum parathormone levels and progressive bone disease in the presence of normal serum phosphate and calcium levels were treated by subtotal parathyroidectomy. All had parathyroid hyperplasia. Eighteen of the 22 patients are presently alive and undergo dialysis. Symptoms of bone pain, pruritus, and muscle cramps had improved in three fourths of the patients. The serum parathormone level decreased from a preoperative average of 576 muLEq/mL to an average of 188 muLEq/mL postoperatively. All 18 patients, observed for six to 77 months, showed improvement in x-ray films of their bone disease. The autonomous hyperparathyroidism of end-stage renal disease is corrected by subtotal parathyroidectomy, and the effect is sustained.

Donor-specific transfusion with diminished sensitization.

Fourteen mixed lymphocyte culture (MLC)-reactive haploidentical recipients have received donor specific transfusions (DSTs) with diminished sensitization to HLA antigens. A single unit of donor blood was obtained in CPD-A anticoagulant, packed, and transfused in three aliquots at 1-week intervals when the blood was 1, 3, and 5 weeks old. Transplantation, performed 22 to 149 days after the last DST, has been successful in all patients for 3 to 26 months except for one experiencing hyperacute rejection despite a negative crossmatch. In vitro studies suggest that blood storage results in the loss of T lymphocytes, which are presumably responsible for the sensitization, and preservation of B cells and monocytes, which remain capable of stimulating a cellular immune response in vitro throughout the 30-day storage period. Apparently this change in the cellular characteristics of blood with storage produces the salutory effects of blood transfusion without the undesirable sensitization to HLA antigens. The mechanisms remain under study.

Fresh versus stored blood in donor specific transfusion.

Haploidentical, MLC responsive recipients were randomized to receive either fresh (less than 48 hours old) or stored donor specific transfusions (DST). In the stored DST group, one donor unit obtained with CPD-Adenine anticoagulant was split into three aliquots and administered as packed cells after 1, 3, and 5 weeks of storage. While 3/6 fresh DST recipients became sensitized to their donors, 0/12 receiving stored DSTs developed positive donor crossmatches. Eleven patients (three fresh, eight stored) have been transplanted and have had similar posttransplant courses. None of the stored DST recipients has rejected his transplant. Four recipients of stored DSTs are awaiting transplantation. Leukocyte enumeration and FACS analysis of aliquots of stored blood shown that cells bearing HLA-ABC antigens disappear with time while B cells and monocytes persist. Taken in concert, the observations suggest that favorable recipient conditioning for transplantation can take place without sensitization to HLA antigens by simply storing the blood prior to transfusion.

Serum beta-2-microglobulin: an adjunctive monitoring test in renal transplantation.

We have serially measured serum beta 2 M microglobulin in a series of transplant recipients along with other standard clinical parameters. Independent comparison of the beta 2 M results leads to the following conclusions: 1. Beta 2 M is superior to the Scr in detecting acute rejection, with diagnostic elevations occurring 2 to 7 days before Scr increase. The observation is valid for all rejection episodes. 2. Beta 2 M decreases prior to or simultaneously with the Scr following successful rejection therapy or beginning resolution of acute tubular necrosis. 3. Abnormal beta 2 M following rejection therapy invariably heralds another rejection episode within 10-20 days, despite the Scr having returned to baseline. 4. Beta 2 M remains normal in high grade ureteral obstruction despite increased Scr. 5. Beta 2 M is remarkably increased in patients with viremia, despite minimal change in Scr. Beta 2 M remains normal in lower UTI from bacterial origin. Beta 2 M appears to be a major contribution in the monitoring of the renal transplant recipient which may have significant impact on therapeutic decisions in the future. In addition, it provides a reliable in vitro parameter which can be used to further assess specific treatment variables in a prospective controlled protocol approach.

Femoral neuropathy and ischemic colitis associated with amyloidosis in hemodialysis patients.

Renal failure is often the presenting problem with amyloidosis and it portends a generally poor prognosis. Two of 121 patients in a home dialysis program were found to have amyloidosis after they developed unusual complications, ischemic colitis and femoral neuropathy. Both ultimately died as a result of their disease. From the limited experience that is reported, it appears that renal transplantation offers a better alternative for long term therapy than hemodialysis.

Bovine graft fistulas in patients with vascular access problems receiving hemodialysis.

Thirty-three bovine grafts were placed in 28 patients for vascular access for hemodialysis. The indications were lack of shunt sites and anticoagulation with Coumadin in patients without vessels suitable for construction of a primary arteriovenous fistula. All but one of the grafts were loops placed in the forearm. There were 20 complications associated with the 33 procedures. Three patients required replacement of the initial graft in the early postoperative period due to thrombosis. One additional patient required two graft replacements and eventual anticoagulation with Coumadin before a successful result was obtained. There have been no serious ischemic problems. Presently, there are 27 functional bovine grafts, and 68 per cent of these are currently used for vascular access for dialysis. Patient acceptance of the fistulas has been good. The loop bovine graft fistula in the arm is an excellent means for vascular access in the patient receiving hemodialysis.

The risk of anticoagulation in hemodialysis patients.

The risks of intermittent anticoagulation with heparin for hemodialysis and longterm anticoagulation with warfarin to prevent clotting of arteriovenous shunts were assessed in a group of 125 home dialysis patients. Over a 7-year period, there were nine bleeding complications attributable to heparin anticoagulation for an incidence of one complication for every 40 patient year on dialysis. In contrast, 20 of 48 patients anticoagulated with warfarin for an average of 2 years each, had a total of 50 hemorrhagic complications requiring 542 days in the hospital and 15 operative procedures. Concersion to an alternative form of vascular access, the internal arteriovenous fistula, obviated the need for warfarin therapy and its unacceptably high complication rate in this population of patients.