Progressive multifocal leukoencephalopathy in renal transplant recipients.

Progressive multifocal leukoencephalopathy, a slowly progressive papovavirus infection of the CNS, has been reported in more than 110 patients to date, over half of whom have had either leukemia or lymphoma. Our patient is the fourth case of PML occurring after long-term immunosuppression for renal transplantation. We believe that PML is emerging as a potentially serious problem in renal transplant recipients.

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.

The nephrotic syndrome associated with neoplasia: an unusual paraneoplastic syndrome. Report of a case and review of the literature.

The nephrotic syndrome complicating malignancy in the absence of renal vein thrombosis, amyloid or neoplastic infiltration of the kidney is an unusual occurrence. A case of diffuse, well differentiated, lymphocytic lymphoma and lipoid nephrosis documented by light microscopy, electron microscopy and immunofluorescent studies is reported. A review of the literature revealed 76 case reports in which the nephrotic syndrome was associated with neoplasia. The most frequently associated neoplasms are Hodgkin's disease, various carcinomas, nonHodgkin's lymphoma and leukemia in descending order. The most frequent renal lesion in patients with the nephrotic syndrome associated with various carcinomas is membranous glomerulonephritis (81 per cent) as opposed to patients with lymphomas or leukemias who have predominantly lipoid nephrosis (60 per cent). The evidence is reviewed suggesting that the lesions in membranous nephropathy are immunologically mediated by tumor or viral antigen-antibody complexes and in lipoid nephrosis perhaps by a defect in t-lymphocyte function.

Inability of thoracic duct drainage to prevent hyperacute rejection.

Serum and lymph albumin and Ig levels were measured during 6 weeks of lymphocyte depletion by thoracic duct drainage (TDD) in 21 patients prior to renal allotransplantation. In ten of these patients, the amount of protein lost from all sources (blood sampling, dialysis, and lymph centrifugation) was measured. The total amount of albumin lost was significantly greater than the amount of IgG lost. However, serum IgG declined at a faster rate and to a greater extent than albumin. Hyperacute or acute humoral rejection occurred in 14 grafts in 10 patients prepared by TDD despite negative crossmatch tests. These data suggest that removal of lymphocytes by TDD, rather than protein loss alone, affects IgG levels. On the other hand, TDD and IgG depletion do not prevent hyperacute or acute humoral rejection. This is most likely due to the inability of currently employed crossmatch tests to predict accurately which patients will manifest antibody-mediated graft rejection.

Lymphocele: a significant complication following renal transplantation.

Six pelvic lymphoceles occurred in a series of 88 renal transplants. All of the patients had ipsilateral leg edema and one-half had a urinary tract infection and/or pain. Displacement of the urinary bladder away from the kidney with or without some degree of ureteral obstruction was diagnostic. External or internal drainage resulted in reliev of the symptoms.