Management of synchronous renal neoplasm and abdominal aortic aneurysm.

OBJECTIVES: Renal neoplasm (RN) and abdominal aortic aneurysm (AAA) are occasionally discovered concurrently. The approach to synchronous malignancy and aortic aneurysm is controversial. METHODS: Between 1981 and 1999, concurrent RN and AAA were diagnosed in 50 patients at the Cleveland Clinic Foundation. Twenty-three patients were managed conservatively because of small asymptomatic AAA or metastatic disease; these patients were excluded from the study. The remaining 27 patients underwent operative management of both entities with a staged or simultaneous approach, and they form the basis of this article. RESULTS: AAA diameter ranged from 4.8 to 13 cm (mean, 6.0+/-1.8 cm). RNs were managed with radical nephrectomy in 11 patients (41%), partial nephrectomy in 10 patients (37%), or both in 6 patients with bilateral renal tumors (22%). The AAA repair was performed at the time of the urologic procedure in 11 patients (41%), before the urologic procedure in 13 patients (48%), or after the urologic procedure in 3 patients (11%). The AAA was addressed with open surgical repair in 24 patients (89%); recently, three patients (11%) underwent endovascular repair of the aneurysm and staged partial nephrectomy. The incidence of major perioperative complications was 23% (6 patients). Acute renal failure was the most common complication (3 [11%]) followed by acute respiratory failure (2 [7.4%]), pulmonary embolism (1 [3.7%]), and stroke (1 [3.7%]). At the mean follow-up of 57 months, there were no graft infections reported. The 5-year overall and cancer-specific survival rates were 62% and 81%, respectively. There was a significant difference in 5-year cancer-specific survival when comparing patients managed simultaneously versus staged (80% versus 35%, P =.007). CONCLUSIONS: The concurrent presentation of RN and AAA should not discourage one from treating both entities simultaneously because long-term survival is common. Endovascular repair of AAA holds promise as an attractive strategy in these complex patients.

Association between a positive flow cytometry crossmatch and the development of chronic rejection in primary renal transplantation.

OBJECTIVES: With the current repertoire of immunosuppressants available, the results of organ transplantation are now very good in the short term. However, many grafts continue to be lost in the long term because of chronic rejection. This study examined the effect of kidney transplantation against a positive flow cytometry crossmatch (FCXM) on the subsequent development of chronic rejection and graft failure. METHODS: We examined 187 primary renal transplantations performed at our institution between 1993 and 1996. All of these patients had a negative cytotoxicity crossmatch. All had a pretransplant FCXM, and patients were divided according to the results of the FCXM into three categories: FCXM negative, FCXM class I positive, and FCXM class II positive. RESULTS: We found that a positive FCXM at the time of transplantation was strongly associated with the ultimate development of chronic rejection. In FCXM-negative individuals, 16.9% developed chronic rejection compared with 80% of those with an HLA class I (T and B-cell) reaction and 40.9% of those with a class II (B-cell-only) reaction (P <0.001). The 3-year graft survival rate was 93% for FCXM-negative patients compared with 86% for FCXM class II positive and 80% for FCXM class I positive patients (P = 0.001). CONCLUSIONS: A strong association between a positive FCXM and subsequent development of chronic rejection was identified. This finding raises the possibility that more aggressive treatment of patients with a positive FCXM might ultimately result in a lower incidence of chronic rejection and improve overall graft survival.