Page Kidney Following a Nonepisode Protocol Renal Allograft Biopsy: A Case Report.

Page kidney refers to a clinical condition that is characterized by the acute onset of hypertension and renal dysfunction owing to external compression of the kidney by a hematoma, tumor, lymphocele, or urinoma. We report a case in which Page kidney occurred after a nonepisode protocol renal allograft biopsy. A 31-year-old man with end-stage renal disease received a living related kidney transplant from his father. One year later, a nonepisode protocol renal allograft biopsy was performed. A day later, the patient's serum creatinine level increased to 4.23 mg/dL, and a subcapsular renal hematoma was detected using ultrasonography and computed tomography. Page kidney was diagnosed, and immediate surgical removal of the hematoma was performed. Nine days after the operation, the patient's serum creatinine level had improved to 1.89 mg/dL. Page kidney is a serious but treatable complication of renal allograft biopsies, and clinicians should pay attention to such complications, even in the setting of nonepisode protocol renal allograft biopsies.

Orthotopic Kidney Transplantation in an Elderly Patient With Various Severe Comorbid Conditions: A Case Report.

In recent years, the frequency of high-risk kidney transplantations has increased. We report a case in which a 72-year-old man with various severe comorbidities (prostate cancer, diabetes mellitus, complete atrioventricular block, coronary artery stenosis, severe stenosis of the popliteal arteries, and severe calcification of the iliac arteries) who received an orthotopic kidney transplantation. To prevent the occurrence of acute limb ischemia due to the steal phenomenon (caused by the kidney graft), we decided that a heterotopic kidney transplantation involving the iliac arteries was not an appropriate option. Therefore, as an alternative, left native nephrectomy was performed followed by an orthotopic kidney transplantation to the native renal artery and renal vein through a left subcostal incision. Postoperative ureteral stenosis occurred, and so stent exchange was required every 6 months. Despite the ureteral complication, the patient's serum creatinine level was 1.5 mg/dL at 2 years after the procedure.

Pathologic Features of Parathyroid Glands Associated With the Pathogenesis of Long-lasting Persistent Hyperparathyroidism After Kidney Transplantation in Long-term Dialysis Patients.

BACKGROUND: Persistent hyperparathyroidism in kidney transplant recipients may be prolonged for a few years, and in these cases, parathyroidectomy is indicated even if graft function is satisfactory. The aim of this study was to characterize the parathyroid glands in long-term dialysis recipients and determine the pathogenesis of persistent hyperparathyroidism. METHODS: We analyzed 44 parathyroid glands resected from 11 patients who underwent parathyroidectomy after kidney transplantation. The histopathologic types and weights of all the parathyroid glands were evaluated. RESULTS: The mean dialysis period was 15.8 years, and the time from kidney transplantation to parathyroidectomy ranged from 3.5 to 89 months. Nodular hyperplasia was present in parathyroid glands in all cases. The mean glandular weight was 396.0 ± 299.0 mg, and the maximum glandular weight was 3200 mg. Seven patients who underwent parathyroidectomy >1 year after kidney transplantation (late PT) were compared with 4 patients who underwent parathyroidectomy within 10 months after transplantation (early PT). The maximum (442.9 vs 1503 mg; P = .018) and mean (312.5 ± 177.4 mg vs 1135.6 ± 977.7 mg; P = .001) glandular weights were significantly lower in patients who underwent late PT compared with those who received early PT. Based on the histopathologic type and glandular weight of each parathyroid gland, nodular hyperplasia in glands ≤150 mg was common in patients who underwent late PT. CONCLUSIONS: The presence of nodular hyperplasia in parathyroid glands with a low weight may be involved in long-lasting persistent hyperparathyroidism in patients undergoing long-term dialysis.

Helicobacter cinaedi bacteremia in four renal transplant patients: clinical features and an important suggestion regarding the route of infection.

Helicobacter cinaedi can cause bacteremia mainly in immunocompromised patients. We present the clinical characteristics of H. cinaedi bacteremia in 4 renal transplant patients. Interestingly, all cases showed triggers of bacterial translocation: 2 cases developed after colonic perforation caused by diverticulitis, 1 case developed post cholecystectomy, and the remaining patient had chronic diarrhea. Accordingly, bacterial translocation caused by severe gastrointestinal complication could be a cause of H. cinaedi bacteremia.

Colovesical Fistula After Renal Transplantation: Case Report.

Colovesical fistula is a relatively rare condition that is primarily related to diverticular disease. There are few reports of colovesical fistula after renal transplantation. We report of a 53-year-old man who was diagnosed with colovesical fistula after recurrent urinary tract infection, 5 months after undergoing cadaveric renal transplantation. Laparoscopic partial resection of the sigmoid colon with the use of the Hartmann procedure was performed. Six months after that surgery, there was no evidence of recurrent urinary tract infection and the patient's renal graft function was preserved. Physicians should keep colovesical fistula in mind as a cause of recurrent urinary tract infection in renal transplant recipients, especially in those with a history of diverticular disease.

Hand-assisted technique facilitates preserving graft viability in laparoscopic donor nephrectomy.

BACKGROUND: To achieve patient safety and minimal operative invasion in living kidney donor nephrectomy, we have performed hand-assisted laparoscopic donor nephrectomy (HALDoN) since 2006. AIM: The aim of this study was to evaluate the utility and the technique of HALDoN. METHOD: We analyzed 72 donors who underwent HALDoN from February 2008-August 2011. RESULTS: Including 8/72 donors who underwent right nephrectomy, all subjects completed HALDoN without conversion to an open procedure. None of the recipients suffered delayed graft function or an ureteric problem. Knife-to-removal time (KRT) was longer among cases with graft weight (GW) >200 g than GW ≤200 g: 176.5 ± 35.1 minutes vs 142 ± 18.7 minutes (P < .001). Longer KRT (>180 minutes) and right nephrectomy produced longer reperfusion-to-urine secretion time (RUT; P = .002 and P = .027, respectively). Grafts with double renal arteries (N = 10) also tended to show longer RUT (P = .058). In a case with an early renal arterial branch <1 cm from the aorta, we transected the vessel to achieve a single orifice of the artery using a stapling device. At 6 months the average value of decreased renal function of donors had recovered to about 70%. The incidence of complication was 8.3% but there was no life-threatening morbidity. CONCLUSION: The hand-assisted method could make the operating surgeon more confident to perform laparoscopic donor nephrectomy safely. HALDoN offers particular advantages for precise dissection using finger retraction and control of potential bleeding in the stages of vascular stapling and graft removal, preserving graft viability.

A case of familial lecithin-cholesterol acyltransferase deficiency on hemodialysis for over 20 years.

We trace the 34-year history of a member of the first Japanese family in which lecithin-cholesterol acyltransferase (LCAT) deficiency was diagnosed. Marriage between cousins with low LCAT activity was responsible for familial LCAT deficiency (FLD). In 1976, a 27-year-old Japanese man was noted to have FLD based on proteinuria, hematuria, grayish corneal opacity and low LCAT activity (9.83%). Genetic analysis showed insertion of G-G-C coding glycine at codon 141. Total cholesterol (C) was low at 108 mg/dl and the ratio of C-ester to total C was very low (12%), while the lecithin (phosphatidylcholine) level was very high (97.3%). When his serum creatinine reached 2.6 mg/dl at the age of 41 years (in 1991), renal biopsy was performed. This showed expansion of the mesangial matrix and irregularly thickened capillary walls with a bubble-like appearance because of lipid deposits consisting of two components (partly lucent vacuolated areas and partly deeply osmiophilic areas). Magnification of the latter deposits showed curvilinear and serpiginous striated membranous structure. Hemodialysis was started in 1990 and has been continued for over 20 years until August 2010. Clinical problems have included AV shunt failure requiring 4 operations and 13 percutaneous transcatheter angioplasty procedures, as well as episodes of hemolytic anemia that subsided after infusion of fresh frozen plasma. Cardiovascular events have not yet occurred, although severe calcification of abdominal aorta has been detected by computed tomography.

New thiocholine ester substrates for the assay of human serum cholinesterase.

BACKGROUND: Several thiocholine alkanoyl esters were newly synthesized and explored as substrates for the assay of human serum cholinesterase after being subjected to the Ellman reaction (Arch Biochem Biophys 1958;74:443-50 and Arch Biochem Biophys 1959;82:70-7). METHODS: We synthesized thiocholine ester iodides by the method of Renshow et al. (J Am Chem Soc 1938;60:1765-70). We examined solubility in H(2)O, substrate specificity serum for cholinesterase, (spontaneous) self-hydrolysis, storage stability, and reaction conditions for measurement of the activity of the enzyme. RESULTS: Isobutyryl and cyclohexane-carboxyl esters showed the best efficiency for the specific and stable assay of human serum cholinesterase. Aqueous solubility of each was >10 mmol/L, and the reactivity with acetylcholinesterase was negligible. For isobutyryl and cyclohexane-carboxyl esters, respectively, spontaneous hydrolysis in the aqueous phase was approximately 1/25 and approximately 1/175 slower than the enzymatic hydrolysis, and assays with these substrates were linear to 1800 and 3000 U/L, respectively. The K(m) values of these acylthiocholines with human cholinesterase were almost equivalent (6.9 x 10(-3) mmol/L). The substrates were stable in aqueous solution and in the solid state as the iodides for at least 5 years at 5 degrees C. CONCLUSIONS: The isobutyrate and cyclohexane-carboxylate of thiocholine are suitable for the specific assay of human serum cholinesterase.

Two-dimensional alterations of myenteric plexus in jejunoileal atresia.

PURPOSE: The purpose of this report is to investigate changes in the myenteric plexus associated with the dilated proximal segment of jejunoileal atresia (JA). Two-dimensional morphologic changes in the myenteric nerve plexuses were investigated using whole-mount preparation. METHODS: Proximal (P) and distal (D) intestinal segments from 7 cases with JA and control (C) segments from 5 postmortem neonates were investigated. The circumference of the jejunoileal segments was measured after fixation. Antibodies for protein gene product 9.5 and neurofilament protein were used in whole-mount preparation. The sizes of neural networks were calculated by measuring the longest circular distance in a neural network (x) and the longest longitudinal distance (y), and the width of the internodal strands (i) with a videomicrometer. RESULTS: Median circumference of the segments was 8.5 in P, 2.0 in D, and 2.0 cm in C. The neural networks in P were expanded longitudinally as well as circularly (x = 817.10 microm, y = 561.26, i = 31.04: median) while comparing them to those in D (x = 431.40 microm y = 288.07, i = 26.05) or C (x = 285.03 microm y = 372.20, c = 1113.57, i = 32.39). The nerve plexus was less expanded than the intestinal wall. CONCLUSIONS: Proximal intestinal segments showed a restructuring that resulted in mild hypoplasia of the enteric nerve plexuses in the proximal segments. The less expansion of the myenteric nerve plexus seen in the proximal bowel in infants with JA suggests a histologic basis for the efficacy of tapering or plication of the dilated bowel.

Reversal of portal flow after acute rejection in living-donor liver transplantation.

Portal hepatofugal flow is rare after liver transplantation. We experienced a case in which hepatofugal portal flow was observed in acute rejection. A 6-year-old boy with glycogen storage disease type Ia underwent living-donor liver transplantation. On postoperative day 7, portal venous peak velocity was markedly decreased without portal thrombosis and obstruction of the hepatic vein, and hepatic arterial peak velocity increased reciprocally. Based on a diagnosis of acute rejection, made on postoperative day 8, we initiated steroid pulse therapy. Despite the employment of this therapy, continuous hepatofugal portal flow was observed in the entire liver on postoperative day 8. On day 12, as the liver disorder progressed, the Doppler waveform in the portal vein changed from continuous to pulsatile hepatofugal flow. The patient died of liver failure on day 14. The histological findings of a biopsy specimen on day 9 showed centrilobular necrosis, while total hepatocellular necrosis was seen at autopsy. Hepatofugal flow after liver transplantation is considered to be an ominous sign caused by several factors, and its appearance indicates a fatal condition.

Multi-enzyme reference material from established human cell lines and human sources.

A multi-enzyme reference material was prepared from seven enzymes of asparatate aminotransferase (AST, EC 2.6.1.1), alanine aminotransferase (ALT, EC 2.6.1.2), alkaline phosphatase (ALP, EC 3.1.3.1), lactate dehydrogenase (LD, EC 1.1.1.27), creatine kinase (CK, EC 2.7.2.2), gamma-glutamyltranspeptidase (gamma-GT, EC 2.3.2.2) and amylase (AMY, EC 3.2.1.1) which were purified from human sources including established human cell lines. The enzymatic properties of the material closely resembled those of human serum. In lyophilized form the preparation was stable for at least 200 days when stored at 40 degrees C. Intermethod comparisons of the enzyme activities in 80 clinical specimens were done by correcting the mean values with calibration constants for different assay methods resulting from use of a human serum, the multi-enzyme reference and a commercial control serum. The results from the comparison for the six enzymes of AST, ALT, LD, CK, gamma-GT and AMY in use of the multi-enzyme reference were almost the same as those with use of a human serum as a calibrator, but were not satisfactory for ALP. Even though further search for more reliable material for ALP is required the multi-enzyme reference material can be used for standardization in clinical chemistry.

Ischemic injury in cirrhotic livers: an experimental study of the temporary arrest of hepatic circulation.

In order to prevent massive bleeding at hepatectomy, the temporary arrest of hepatic circulation is often performed but it is not clear whether this arrest of circulation is tolerated equally by the cirrhotic liver and the normal liver. We investigated biochemically the detailed effects of ischemia on cirrhotic livers in rats with experimentally induced liver cirrhosis. Thioacetoamide was used to prepare the rat cirrhotic liver model (LC group, n = 6). After laparotomy, the vessels to the left lateral lobe were clamped for 30 min and then declamped. Changes in AST isozymes and the aminogram in the blood were examined after ischemia. Postischemic changes in hepatic adenine nucleotides (AdN) and the brain aminogram were also examined. These were compared with those of normal liver ischemia (N group, n = 6) at 24 hr after recirculation. In the LC group, serum levels of mitochondrial AST, a parameter of necrotic cells, were significantly higher than those of the N group. Hepatic AdN levels decreased to 60.6% of the original levels after ischemic injury but those of the N group remained at 95.4% of the original level. Since AdN in tissue is accepted as a reliable parameter of viable cells, cirrhotic livers subjected to ischemia might have more necrotic cells than normal livers. Sequential analysis of serum aminograms of the LC group after ischemia revealed that the ratio of Val+Leu+Ileu/Tyr+Phe decreased to near 1.0 but that of the N group always remained higher than 3.0. Based on these results, it was concluded that ischemic injury in cirrhotic livers is more hazardous than that in normal livers.

An acoustically investigated case of phonetic change in higher vertical dimension.

This report presents the phonetic changes of a patient whose occlusal vertical dimension is extended. His chief complaint is esthetic restoration of his anterior teeth, but his occlusal vertical dimension is abnormally shortened by long-time attrition. Therefore we extended his occlusal vertical dimension, and reconstructed his occlusion, and carried out acoustic observations.

[Acousticodynamic investigation of palatal rugae given by the pressure impression method].

This time, we used palatal plates with the individual palatal rugae using the plastic plate for copying the individual palatal rugae easily, and studied the influence of the pronunciation concerning the changes of the Formant frequencies with Sound Spectrograph.

Improvement of speech sound disorder with figure deformation case to a bone-defected patient.

This report describes improvement of pronuciation in a bone-defected patient with a partial denture. The patient's chief complaints were difficulty of fricative and africative consonant utterance. Insertion of partial denture improved the pronunciation to some degree. Furthermore, the patient's figure deformation was corrected.

An acoustic investigation caused by pontic formation.

Prosthetics for cases with large defects of alveolar bone often tend to be difficult. We researched the acoustic effects of various pontic forms to satisfy a patient's expectations for both phonetics and aesthetics.