Arteriovenous fistulas for long-term dialysis. Factors that influence fistula survival.

We reviewed our total experience with arteriovenous (AV) fistulas for long-term hemodialysis. We are unable to show any significant difference in the survival of AV fistulas based either on the type of material used to create the fistulas or on their location. Complications encountered early in this experience largely were due to technical or judgmental errors. Thrombosis of radiocephalic fistulas resulted from failure to use a vein of adequate caliber. Failure of bovine artery heterograft AV fistulas resulted either from wound infection or from the use of a diseased artery that was incapable of delivering sufficient blood to keep the fistula open. Infection around a heterograft fistula frequently was associated with a lymphocele. The meticulous division, between clips or ligatures, of all tissues deep to the skin prevented lymphocele formation.

Quantitative renal scintillation camera studies in renal transplantation.

Renal transplant recipients and donors were studied serially with quantitative renal scintillation camera studies utilizing 131I-Hippuran and 99mTc-Iron ascorbate. This study allows for determination of effective renal plasma flow (ERPF), glomerular filtration rate (GFR), filtration fraction (FF), and predicted return in ten minutes. A drop in FF occurred with, or preceded clinical rejection; whereas, an increase in FF occurred with acute tubular necorsis (ATN) caused by preservation injury, aminoglycosides, and following acute rejection. Combined with the other parameters of renal function determined by this technique, FF alterations proved useful in the differentiation of ATN from rejection and in predicting the prognosis of renal homografts.

Anuria secondary to percutaneous needle biopsy of a transplant kidney: a case report.

Unexplained deterioration of renal function after renal transplantation is often an indication for percutaneous needle biopsy of the allograft. This procedure, even when supplemented by modern radiographic techniques, is not without complications. We report a case of anuria secondary to subcapsular hematoma following an ultrasound-guided needle biopsy. Diagnosis, operative management and postoperative care are discussed.

External ureteroneocystostomy and ureteroureterostomy in renal transplantation.

"External" ureteroneocystostomy is a method of reconstructing the urinary tract for renal transplantation. As performed by us, it is a modification of the technique of Witzel, Sampson, and Lich. It has the advantages of requiring a very short length of ureter, avoiding a separate and large cystotomy, and retaining the antireflux mechanism. This technique is described in detail. Ureteroureterostomy has been used as the preferred procedure when the bladder wall is very thin or when the vascular attachments are such that a ureteral length of greater than 6-7 cm would be required for bladder implantation. Since using these techniques we have reduced the early complication rate of ureteral implantation from 11.9% in a consecutive series of 126 transplants to 0% in the last 88 consecutive transplants. A review of the literature which led to the adoption of these techniques is also presented.

Reversal of Urinary tract diversion after recovery from hysterical conversion reaction.

We have described a case in which the diagnosis of multiple sclerosis with findings of progressive paraplegia and a neurogenic bladder led to supravesical urinary diversion. Pyocystis led to creation of a urethrovesicovaginal fistula. Psychotherapy later uncovered hysterical conversion reaction. Which was cured with hypnotherapy. The urinary tract diversion was subsequently reversed after reconstruction of the bladder and urethra.

Ureteral obstruction due to blood clot following percutaneous renal biopsy: resolution with intraureteral streptokinase.

The nonsurgical approach to unilateral ureteral obstruction due to impaction of a blood clot is described. A patient with the nephrotic syndrome secondary to minimal change disease had gross hematuria and acute renal failure following percutaneous renal biopsy. After he responded to prednisone therapy, clot obstruction developed at the site of the percutaneous biopsied kidney, which was treated with intracaliceal infusion of streptokinase via a ureteral catheter. Complete resolution of the clot and the urinary tract obstruction was accomplished within 3 days. This approach appears to be the treatment of choice in upper urinary tract obstruction secondary to blood clots when simple ureteral catheter drainage is ineffective.

The quest for living-related kidney donors for children with end-stage renal disease.

In a pediatric renal transplant program that actively seeks living-related kidney donors, we achieved a living donor rate of 55% in 119 children. This approximates the national average but is less than an idealized goal. For black children, the living-donor transplant rate was 41%, a disconcertingly low rate. In an attempt to define factors that negatively affected living-related donor availability, we analyzed our evaluation process by distinct phases (interview, histocompatibility testing and medical evaluation). We classified our families on the basis of locale (urban, suburban and rural), family unit (two or less parents, adult sibs or other relatives presenting at interview) and economic status (designating only economic-disadvantaged and other). While histoincompatibility is predictably a negative factor, the negative impacts of medical illness in the donor pool, economic disadvantage and single parent family are striking and cumulative. Our data validate the relative success of an aggressive recruitment policy in a patient population that includes many economically disadvantaged families. For pediatric renal transplant programs with low living-related donor rates, our data should encourage review and possible modification of the donor recruitment process.

Effect of extracorporeal shock wave lithotripsy on renal function and body height in pediatric patients.

Although extracorporeal shock wave lithotripsy (ESWL) is the preferred modality for treatment of most renal and upper ureteral calculi in adults, little is known about its effect on the pediatric population. We carefully followed 12 children 2.2 to 15.3 years old (mean age 9.4) treated with the Dornier HM3 lithotriptor. Effective renal plasma flow was obtained by quantitative 131iodine hippurate scan immediately preceding ESWL and at followup (range 74 to 238 weeks, mean 149). The treated kidney received an average of 1,702 shocks (range 1,000 to 2,200). Mean effective renal plasma flow increased in the treated kidney from 185 cc per minute before ESWL to 217 at followup (p = 0.016) and in the untreated kidney from 191 to 224 (p = 0.0013). Total effective renal plasma flow increased from 376 cc per minute before ESWL to 440 at followup (p = 0.0019). In the treated kidney mean and total effective renal plasma flow increased by 31 (expected 32) and 64 (expected 68) cc per minute, respectively, while in the nontreated kidney mean effective renal plasma flow increased by 33 (expected 36) cc per minute. None of the observed changes in effective renal plasma flow was significantly different from the expected changes using the paired t test at the 95% level. In addition, change in body height was evaluated using standard deviation scores. Mean body height (standard deviation) before ESWL was -0.39 (range -3.2 to 2.0) and at last followup it was -0.26 (range -2.6 to 2.4), which is not statistically significant (p = 0.37). Although these patients continue to be followed and caution is advised, this long-term study indicates that ESWL within the range of shocks delivered to this cohort does not statistically affect linear growth (body height) or renal function in the pediatric population.

Renal allograft rupture: a clinical review.

Rupture of a renal allograft (RAR) is an uncommon but serious complication of renal transplantation. A recent RAR prompted a review of our experience, with the purpose of (1) identifying conditions that may predispose this complication and (2) defining strategies for prevention. A 5-yr, consecutive living-related (LRD) and cadaver donor (CD) cohort of 331 patients was studied retrospectively. Twelve patients (3.6%) had RAR. Donor characteristics, procurement and preservation conditions, and recipient characteristics were major study categories. Data analysis was computer-based and included multivariate analysis. The nine White and two Black cadaver donors were "ideal", mean age 29 yr, with mean high creatinine (CR) of 1.3 and terminal CR of 1.1 mg/dl and mean terminal urine output of 423 ml/min. Nine of 11 CD had low-dose dopamine use (terminal, mean 8, range 5-13 micrograms/kg/min). Eleven of 11 donors had procurement en-bloc, 9 of which were multiple organ procurement. All had 4+/4+ flush and cold storage with UW solution. Mean cold ischemia time (CIT) was 22 h, 28 min (range 15 h, 16 min to 40 h). For patients with RAR mean age was 39 yr; there were 12 Black patients and 7 males, 5 females. HLA match was 1 antigen (AG) for 3, 2 AG for 8, and 4 AG for 1 (mean 1.9). Nine patients had delayed or declining renal function requiring dialysis. The panel reactive antibody was at peak, mean 47% (range 0-100%) and current, mean 18% (range 0-84%). Six of 12 had OKT3 therapy at time of RAR and six had biopsies. Day of RAR was mean 10, median 9 (range 4-21). Pain and drop in hematocrit were observed in most. There was one fatality (8%), and all kidneys were removed. All kidneys showed at least minimal rejection but six had severe acute tubular necrosis (ATN) with edema and minimal rejection. Statistically significant associations with RAR were older recipient age (p = 0.01), donor-recipient race mismatch (White donor to Black recipient) (p = 0.007), and dialysis requirement (p < 0.001). Other variables were not statistically correlated: gender, race, CIT, transplant number, LRD vs. CD, peak or current PRA, and total HLA and BDR mismatch. The data suggest that ATN and rejection act synergistically to cause RAR and that early delayed function requires intensive and perhaps novel immunosuppression, especially in Black recipients.

Treating men with predominantly nonpsychogenic erectile dysfunction with intracavernosal vasoactive intestinal polypeptide and phentolamine mesylate in a novel auto-injector system: a multicentre double-blind placebo-controlled study.

OBJECTIVE: To study the effect of intracorporeal injection (IC) of vasoactive intestinal polypeptide (VIP) and phentolamine mesylate (PM) on men with erectile dysfunction (ED) of nonpsychogenic aetiology. PATIENTS AND METHODS: The study comprised 236 men with primarily nonpsychogenic ED attending sexual dysfunction clinics at eight institutions. In an initial dose-assessment phase, the men were given IC injections of 25 micrograms VIP combined with PM 1.0 mg (VIP/P-1) or 2.0 mg (VIP/P-2) in a prefilled, single-use auto-injector. The main aetiologies of ED were arteriogenic (38), diabetes mellitus (DM) (39), neurogenic (35), mixed (90), and venous leakage (30). In a placebo-controlled phase, 171 patients were subsequently treated and self-administered up to 12 injections over a 6-month interval. RESULTS: In the dose-assessment phase there was an overall response rate of 82%, with responses by aetiology as follows: arteriogenic (82%), DM (85%), neurogenic (86%), mixed (80%), and venous leakage (77%). In a subgroup of 159 patients who withdrew from previous IC therapies for ED, 64% responded with an erection suitable for intercourse. Of the 171 patients treated in the placebo-controlled phase, 75% responded to VIP/P-1 and 12% to placebo (P<0.001); 66% responded to VIP/P-2 and 18% to placebo (P<0. 001), with a median duration of erection of 56 min. The principal adverse event was transient facial flushing accompanying 40% of 1711 injections. There was no pain after injection and one episode of priapism (0.06%); only seven patients withdrew because of adverse events. Over 88% and 92% of patients were satisfied with the drug and auto-injector, respectively. More than 85% of patients and 77% of partners reported an improved quality of life. CONCLUSION: The combination of VIP and PM at the dose used is a safe and effective means of treating male ED of primarily nonpsychogenic aetiology.

Renal transplantation in a developing country: anesthesia and other considerations.

The Renal Transplant Team at Tulane University Medical Center has been involved in training a multispecialty group of Guatemalan physicians to perform renal transplantations in Guatemala. The purpose is to train the physicians in their own country, using available equipment and personnel so that they can perform successful operations in our absence. This paper is a review of the considerations involved in the initial renal transplantation done in Guatemala by the Tulane Renal Transplant Team. The need for a preliminary site visit was paramount. Personnel, facilities, and both surgical and anesthesia equipment and supplies were carefully evaluated. The recipient was a 22-year-old man with end-stage renal disease due to chronic glomerulonephritis. The donor was a healthy 33-year-old brother. This article is not intended to review renal transplantation in the United States, but to show what is feasible in a developing country where many drugs and equipment are not available.