RESUMO
Thymoglobulin (rATG), polyclonal immunoglobulin, is prepared from rabbits immunized with human thymocytes. It is effective in prevention and treatment of renal allograft rejection. Human antibodies against antilymphocyte preparations can reduce efficacy by accelerating drug clearance or by inducing serum sickness. We developed an enzyme-linked immunosorbent assay (ELISA) to study posttreatment development of anti-rATG. In an Institutional Review Board-approved trial, we tested 101 allograft recipients for anti-rATG antibodies. Patients received rATG intravenously at 1.25 to 2.0 mg/kg/d for 2 to 14 days. Serum samples were obtained pretreatment and at weeks 1, 2, 4, 6, and months 3 and 6 post-rATG. ELISA plates were coated with rATG (10 microg/mL). Samples were diluted 1:100 and tested in quadruplicate. Positive samples were titrated. Horseradish peroxidase-conjugated (HRPO) affinity-purified goat anti-human immunoglobulin G (H&L) antibody reacted with bound human antibody. A chromagenic substrate for HRPO was added and optical density (OD, 490 nm) was read. An OD of twice the negative control was considered positive. Mean ODs of negative and positive controls were 0.113 +/- 0.030 and 1.042 +/- 0.196, respectively. Ten patients had detectable anti-rATG before rATG administration (1:100). Thirty-five of 101 patients (35%) developed anti-rATG antibody. Patients showed an initial positive anti-rATG antibody from days 8 to 59 after infusion and titers from 1:100 to 1:4000. In spite of rATG's postulated anti-B-cell activity, this study confirms that rATG induces sensitization at a frequency and titer seen with other xenogeneic antilymphocyte antibodies. Formation of such antixenoantibodies can have a negative impact on treatment response and hence warrant monitoring.
Assuntos
Anticorpos Monoclonais/imunologia , Transplante de Coração/imunologia , Isoanticorpos/sangue , Transplante de Rim/imunologia , Transplante de Fígado/imunologia , Transplante Homólogo/imunologia , Animais , Soro Antilinfocitário , Ensaio de Imunoadsorção Enzimática , Humanos , Monitorização Imunológica , Coelhos , Reprodutibilidade dos TestesRESUMO
Questions have arisen regarding the risk of developing symptomatic Histoplasma capsulatum infection among patients who undergo transplant-related immunosuppression in areas endemic for histoplasmosis. Our medical center is located in a hyperendemic area for histoplasmosis, where three large outbreaks occurred since 1978. We undertook a retrospective chart review of 137 patients who received allogeneic bone marrow transplant and of 449 patients who received solid organ transplant from January 1994 to December 1996 in order to assess the incidence of active histoplasmosis. Charts were reviewed before and after transplantation for clinical outcomes, H. capsulatum serologies and antigen results, and microbiological and radiological results. After a mean follow-up duration exceeding 16 months, no patient was diagnosed with histoplasmosis. In the absence of an outbreak, histoplasmosis is a rare infection following the immunosuppression of allogeneic bone marrow or solid organ transplantation even in a hyperendemic area. Pre-transplant serologies or chest radiographs consistent with prior infection were not associated with post-transplant histoplasmosis.
Assuntos
Transplante de Medula Óssea/efeitos adversos , Histoplasmose/epidemiologia , Transplante de Órgãos/efeitos adversos , Transplante Homólogo/efeitos adversos , Adulto , Doenças Endêmicas , Histoplasma/isolamento & purificação , Histoplasmose/microbiologia , Humanos , Incidência , Indiana , Estudos RetrospectivosRESUMO
Laparoscopic technique for excision of a kidney from a living donor has advantages over conventional open surgery, but operative visibility and surgical exposure are limited. Preoperative multisection computed tomography (CT) can provide necessary anatomic information in a minimally invasive procedure. A three-phase examination is suggested: (a) imaging from the top of the kidneys to the pubic symphysis with a section width of 2.5 mm and no contrast medium, (b) scanning of the kidneys and upper pelvis during the arterial phase of enhancement with a section width of 1.0 mm, and (c) scanning of the kidneys and upper retroperitoneum during the nephrographic phase of enhancement with a section width of 1.0 mm. Emphasis in this article is placed on analysis of the venous anatomy because most radiologists are unfamiliar with the anatomic variations. Conventional radiography of the abdomen and pelvis is performed after CT to evaluate the collecting system and ureters and to provide a lower total radiation dose than if CT were used. Of several postprocessing techniques that may be used, the authors prefer maximum intensity projection for arterial evaluation and multiplanar reformatting for venous evaluation.
Assuntos
Transplante de Rim , Rim/irrigação sanguínea , Rim/diagnóstico por imagem , Nefrectomia/métodos , Tomografia Computadorizada por Raios X/métodos , Humanos , Processamento de Imagem Assistida por Computador , Rim/cirurgia , Laparoscopia , Doadores Vivos , Cuidados Pré-Operatórios , Artéria Renal/anatomia & histologia , Artéria Renal/diagnóstico por imagem , Veias Renais/anatomia & histologia , Veias Renais/diagnóstico por imagemAssuntos
Linfócitos B/efeitos dos fármacos , Infecções por Citomegalovirus/etiologia , Imunossupressores/efeitos adversos , Transplante de Rim/imunologia , Ácido Micofenólico/efeitos adversos , Adulto , Anticorpos Antivirais/metabolismo , Azatioprina/efeitos adversos , Linfócitos B/imunologia , Citomegalovirus/imunologia , Infecções por Citomegalovirus/imunologia , Feminino , Humanos , Masculino , Ácido Micofenólico/análogos & derivados , Estudos RetrospectivosRESUMO
Significant evidence suggests that Chlamydia pneumoniae has a major role in occlusive vascular disease. Vascular access thrombosis in chronic hemodialysis patients is a frequent problem; the underlying pathological state is stenosis caused by endothelial hyperplasia. There is presently no literature concerning C pneumoniae in vascular access thrombosis. We embarked on a study to evaluate the possible role of C pneumoniae in access failure. Ten consecutive patients with thrombosed polytetrafluoroethylene (PTFE) conduit arteriovenous fistulae undergoing surgical thrombectomy and revision were studied. We sought to detect C pneumoniae using both culture and polymerase chain reaction (PCR) methods. An excisional biopsy of the stenotic vein segment just above the anastomosis with the PTFE graft was obtained at surgery. Vein samples weighing at least 30 mg were aseptically placed in transport media and stored at 4 degrees C for up to 24 hours. The samples then were sonicated, inoculated in Hep-2 cell culture vials containing confluent monolayers, and passaged three times over 2 weeks. Detection was by direct fluorescent antibody staining. Both culture and PCR were performed in an active chlamydia research laboratory. None of the 10 samples was positive for C pneumoniae by culture or PCR. Based on our preliminary pilot study, we do not believe C pneumoniae has a major role in endothelial hyperplasia and consequent graft loss in the hemodialysis patients we studied.
Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Prótese Vascular/efeitos adversos , Cateteres de Demora/microbiologia , Infecções por Chlamydia/microbiologia , Chlamydophila pneumoniae/isolamento & purificação , Diálise Renal/efeitos adversos , Trombose/microbiologia , Idoso , Prótese Vascular/microbiologia , Infecções por Chlamydia/etiologia , Endotélio Vascular/microbiologia , Endotélio Vascular/cirurgia , Feminino , Técnica Direta de Fluorescência para Anticorpo , Humanos , Hiperplasia/microbiologia , Hiperplasia/cirurgia , Masculino , Pessoa de Meia-Idade , Técnicas de Amplificação de Ácido Nucleico , Reação em Cadeia da Polimerase , Politetrafluoretileno/efeitos adversos , Trombose/etiologia , Trombose/cirurgiaRESUMO
A case of bacillary angiomatosis infection presenting as a skin nodule in a renal transplant recipient was found. The patient was taking cyclosporine, prednisone, and mycophenolate mofetil at the time of presentation. The bacillary angiomatosis responded to 6 months of therapy with oral erythromycin.
Assuntos
Angiomatose Bacilar/tratamento farmacológico , Angiomatose Bacilar/etiologia , Antibacterianos/uso terapêutico , Eritromicina/uso terapêutico , Transplante de Rim , Adulto , Angiomatose Bacilar/patologia , Ciclosporina/uso terapêutico , Humanos , Imunossupressores/efeitos adversos , Imunossupressores/uso terapêutico , Masculino , Ácido Micofenólico/análogos & derivados , Ácido Micofenólico/uso terapêutico , Prednisona/uso terapêutico , Pele/patologiaRESUMO
BACKGROUND: In the diagnosis of prostate cancer, prostate-specific antigen (PSA) is the most clinically useful tumor marker. Its utility in renal transplant patients is unclear. We hypothesized that PSA values might be affected by the renal function, immunosuppression, or proteinuria. METHODS: Three hundred four PSA values were measured in 166 patients >40 years (53.5 +/- 7.2 years, mean +/- SD, range 44.4 to 76.2). Charts were reviewed for 24-hour creatinine clearance, 24-hour urinary protein, cyclosporine use, age at the time of each PSA test, and evaluation done in response to the PSA result. Analyses used the Mann-Whitney U test and simple regression model. RESULTS: Twenty-five values in 13 patients were >4.0 ng/mL. Of these, 6 patients (6 values) had normal repeat PSA values; 3 patients (11 values) had negative evaluations for prostate cancer; and 4 patients (8 values) were diagnosed with prostate cancer. The latter 4 patients were excluded from the denoted normal group leaving 294 PSA values in 162 patients. The mean normal PSA was 1.3 +/- 1.8 ng/mL, range 0.1 to 20.2. The pretreatment mean PSA for recipients with prostate cancer was 302 +/- 800, range 8.0 to 2,281. An elevated PSA value was associated with a 31% incidence of prostate cancer. There was no association of PSA levels with cyclosporine use, 24-hour creatinine clearance, or 24-hour urinary protein, but there was with age. CONCLUSIONS: Prostate-specific antigen values in renal transplant recipients are similar to those in the general population and are not influenced by cyclosporine or by renal function. We recommend routine measurement of PSA in male transplant recipients.
Assuntos
Transplante de Rim , Antígeno Prostático Específico/sangue , Adulto , Idoso , Creatinina/metabolismo , Ciclosporina/uso terapêutico , Humanos , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Neoplasias da Próstata/diagnóstico , Proteinúria , Estudos RetrospectivosRESUMO
BACKGROUND: This paper reports the histopathologic results of 2-year protocol biopsies from patients who were enrolled in the U.S. FK506 kidney transplant study . METHODS: Recipients of cadaveric kidney transplants were randomized to tacrolimus or cyclosporine therapy. Patients active in the trial at 2 years after transplantation were approached for a protocol biopsy. Biopsies were scored by the Banff classification in a blinded fashion by one pathologist. RESULTS: A total of 144 patients (41.3% of those active at 2 years) had a 2-year protocol biopsy performed; 79 patients were treated with tacrolimus and 65 patients were treated with cyclosporine. Evidence of acute rejection was found in seven (8.9%) of the 2-year biopsies in tacrolimus-treated patients and six (9.2%) cyclosporine-treated patients. Chronic allograft nephropathy was found in 49 (62.0%) tacrolimus biopsies and 47 (72.3%) cyclosporine biopsies (P=0.155). There were no apparent histopathologic differences between the tacrolimus and cyclosporine biopsies. The occurrence of chronic allograft nephropathy was significantly higher in patients who received a graft from an older donor (P<0.01), who experienced presumed cyclosporine or tacrolimus nephrotoxicity (P<0.001), who developed a cytomegalovirus infection (P=0.038), or who experienced acute rejection in the first year after transplantation (P=0.045). A multivariate analysis showed that nephrotoxicity and acute rejection were the most significant predictors for chronic allograft nephropathy. CONCLUSIONS: The occurrence of histologic acute rejection was rare at 2 years, confirming the absence of subclinical acute rejection in these late biopsies. A majority of the biopsies showed features consistent with chronic allograft nephropathy that was associated with acute rejection (particularly in cyclosporine-treated patients), nephrotoxicity, and cytomegalovirus infection in the first year. This suggests that nonimmunologic factors, such as drug-induced toxicity, may play an important role in chronic allograft nephropathy.
Assuntos
Ciclosporina/uso terapêutico , Imunossupressores/uso terapêutico , Transplante de Rim , Rim/patologia , Tacrolimo/uso terapêutico , Adulto , Idoso , Biópsia , Ciclosporina/efeitos adversos , Infecções por Citomegalovirus/etiologia , Feminino , Rejeição de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Tacrolimo/efeitos adversos , Transplante HomólogoRESUMO
An oral formulation of ganciclovir (GAN) has been shown to be effective as prophylaxis of cytomegalovirus (CMV) after liver transplantation in an adult population. There are no data on the use or dose of oral GAN in pediatric transplant recipients. We evaluated the pharmacokinetics of oral GAN in a group of such patients. Nine patients (4 kidney and 5 liver transplant recipients, age 0.9-13 yr) were treated with the commercial formulation of oral GAN after transplant. All patients were considered at risk for CMV disease based on the use of anti-lymphocyte antibody (n = 5), and/or the use of a CMV positive organ in a CMV negative recipient (n = 5) or based on being a recipient of a liver transplant (n = 4). They received oral GAN for 84 +/- 29 d. All recipients had normal renal function as estimated by the Schwartz formula. While on a stable dose of oral GAN for at least 4 d (mean +/- SD 8.4 +/- 7, range 4-27 d), 1-ml serum samples were obtained before and at various times after dosing for the measurement of GAN levels. GAN levels were determined at a central laboratory by high-performance liquid chromatography. In 7 of the patients, a sufficient number of levels were obtained post-dosing to calculate the area under the curve using the linear trapezoidal rule. Cmin, the morning trough concentration, and Cmax, the peak concentration, were determined by inspection. Doses of oral GAN were increased if Cmin levels were less than 0.5-1.0 microgram/ml. Adequate levels of GAN were achieved in these patients at doses of 21.8-38.5 mg/kg or 568-990 mg/m2 every 8 h. There was a better correlation between the maximum GAN blood concentration and body surface area (R2 = 0.52, p = 0.008) than with body weight (R2 = 0.36, p = 0.04). Oral GAN was well tolerated in the 7 patients without evidence of leukopenia, thrombocytopenia, or nephrotoxicity. No CMV disease occurred, although one patient had probable CMV syndrome with the development CMV IgM antibodies. These data suggest that oral GAN may be safely administered to pediatric transplant recipients. With normal renal function, the dosing should be in the range 20-40 mg/kg or 500-700 mg/m2 q 8 h. Further data in children with impaired renal function is required.
Assuntos
Antivirais/farmacocinética , Infecções por Citomegalovirus/prevenção & controle , Ganciclovir/farmacocinética , Transplante de Rim , Transplante de Fígado , Infecções Oportunistas/prevenção & controle , Administração Oral , Adolescente , Antivirais/administração & dosagem , Antivirais/uso terapêutico , Área Sob a Curva , Criança , Pré-Escolar , Ganciclovir/administração & dosagem , Ganciclovir/uso terapêutico , Humanos , LactenteRESUMO
PURPOSE: To determine the incidence and significance of arterial emboli resulting from surgical thrombectomy/revision of hemodialysis grafts. This information may help in determining the significance and management of similar emboli resulting from percutaneous hemodialysis graft thrombolysis. PATIENTS AND METHODS: Patients undergoing surgical thrombectomy/revision of clotted hemodialysis grafts are studied with postoperative fistulography per institutional protocol whenever possible. For this retrospective study, all postoperative fistulograms from a 1-year period were reviewed for the presence of arterial emboli. Patients with documented arterial emboli were examined for evidence of hand/digital ischemia; only those patients with signs or symptoms of ischemia were treated. At clinical follow-up, repeated evaluation for hand/digital ischemia was performed. RESULTS: Ninety-one thrombectomy/revision procedures were performed during the study period. Postoperative fistulograms were obtained after 67 of these procedures in 32 patients. One patient complained of hand pain during dialysis prior to acquisition of the postoperative fistulogram. Arterial emboli were documented in eight patients (12%; brachial, n = 3; radial, n = 2; ulnar, n = 2; radial/ulnar, n = 1). The single symptomatic brachial embolus was percutaneously removed; no intervention was undertaken in the remainder. At mean follow-up of 14 months, no patient had developed hand or digital ischemia. Subsequent fistulograms demonstrated partial (n = 2) or complete (n = 2) resolution of the untreated emboli. CONCLUSION: Arterial emboli are a relatively common occurrence with surgical thrombectomy/revision. Conservative management appears to be indicated in asymptomatic patients.
Assuntos
Cateteres de Demora/efeitos adversos , Oclusão de Enxerto Vascular/cirurgia , Diálise Renal/efeitos adversos , Trombectomia/métodos , Tromboembolia/cirurgia , Angiografia , Artéria Braquial/diagnóstico por imagem , Artéria Braquial/cirurgia , Seguimentos , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Mãos/irrigação sanguínea , Humanos , Incidência , Isquemia/diagnóstico por imagem , Isquemia/etiologia , Isquemia/cirurgia , Diálise Renal/métodos , Reoperação , Estudos Retrospectivos , Tromboembolia/diagnóstico por imagem , Tromboembolia/etiologia , Artéria Ulnar/diagnóstico por imagem , Artéria Ulnar/cirurgiaRESUMO
BACKGROUND: Tacrolimus (FK506), a macrolide molecule that potently inhibits the expression of interleukin 2 by T lymphocytes, represents a potential major advance in the management of rejection following solid-organ transplantation. This randomized, open-label study compared the efficacy and safety of tacrolimus-based versus cyclosporine-based immunosuppression in patients receiving cadaveric kidney transplants. METHODS: A total of 412 patients were randomized to tacrolimus (n=205) or cyclosporine (n=207) after cadaveric renal transplantation and were followed for 1 year for patient and graft survival and the incidence of acute rejection. RESULTS: One-year patient survival rates were 95.6% for tacrolimus and 96.6% for cyclosporine (P=0.576). Corresponding 1-year graft survival rates were 91.2% and 87.9% (P=0.289). There was a significant reduction in the incidence of biopsy-confirmed acute rejection in the tacrolimus group (30.7%) compared with the cyclosporine group (46.4%, P=0.001), which was confirmed by blinded review, and in the use of antilymphocyte therapy for rejection (10.7% and 25.1%, respectively; P<0.001). Impaired renal function, gastrointestinal disorders, and neurological complications were commonly reported in both treatment groups, but tremor and paresthesia were more frequent in the tacrolimus group. The incidence of posttransplant diabetes mellitus was 19.9% in the tacrolimus group and 4.0% in the cyclosporine group (P<0.001), and was reversible in some patients. CONCLUSIONS: Tacrolimus is more effective than cyclosporine in preventing acute rejection in cadaveric renal allograft recipients, and significantly reduces the use of antilymphocyte antibody preparations. Tacrolimus was associated with a higher incidence of neurologic events, which were rarely treatment limiting, and with posttransplant diabetes mellitus, which was reversible in some patients.
Assuntos
Ciclosporina/uso terapêutico , Rejeição de Enxerto/prevenção & controle , Imunossupressores/uso terapêutico , Transplante de Rim/imunologia , Tacrolimo/uso terapêutico , Doença Aguda , Adulto , Soro Antilinfocitário/efeitos adversos , Soro Antilinfocitário/uso terapêutico , Cadáver , Causas de Morte , Protocolos Clínicos , Creatinina/sangue , Estudos Cross-Over , Ciclosporina/efeitos adversos , Diabetes Mellitus/tratamento farmacológico , Diabetes Mellitus/etiologia , Feminino , Rejeição de Enxerto/sangue , Humanos , Imunossupressores/efeitos adversos , Insulina/uso terapêutico , Transplante de Rim/mortalidade , Masculino , Seleção de Pacientes , Análise de Regressão , Tacrolimo/efeitos adversosAssuntos
Ciclosporina/uso terapêutico , Sobrevivência de Enxerto , Imunossupressores/uso terapêutico , Transplante de Rim/imunologia , Tacrolimo/uso terapêutico , Adolescente , Adulto , Idoso , Soro Antilinfocitário/uso terapêutico , Criança , Ciclosporina/efeitos adversos , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/etiologia , Quimioterapia Combinada , Feminino , Rejeição de Enxerto/epidemiologia , Rejeição de Enxerto/prevenção & controle , Humanos , Imunossupressores/efeitos adversos , Transplante de Rim/fisiologia , Masculino , Pessoa de Meia-Idade , Muromonab-CD3/uso terapêutico , Neoplasias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Tacrolimo/efeitos adversos , Estados UnidosAssuntos
Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD8-Positivos/imunologia , Transplante de Rim/imunologia , Receptores de Antígenos de Linfócitos T alfa-beta/biossíntese , Transcrição Gênica , Antígenos CD/análise , Apoptose , Células Cultivadas , Deleção Clonal , Seguimentos , Humanos , Família Multigênica , RNA Mensageiro/biossíntese , Receptores de Antígenos de Linfócitos T alfa-beta/genética , Fatores de TempoAssuntos
Transplante de Células , Fatores de Crescimento de Fibroblastos , Ductos Pancreáticos/citologia , Ductos Pancreáticos/transplante , Células-Tronco/citologia , Animais , Divisão Celular , Células Cultivadas , Técnicas de Cultura , Células Epiteliais , Epitélio/efeitos dos fármacos , Feminino , Fator 10 de Crescimento de Fibroblastos , Fator 7 de Crescimento de Fibroblastos , Substâncias de Crescimento/farmacologia , Humanos , Fator de Crescimento Insulin-Like I/farmacologia , Fator de Crescimento Insulin-Like II/farmacologia , Pancreatectomia , Ratos , Ratos Endogâmicos WF , Células-Tronco/efeitos dos fármacosRESUMO
We report a case of orthotopic liver transplantation, in which portal vein thrombosis developed in the immediate postoperative period. Surgical thrombectomy and intraoperative placement of a large caliber Wallstent resulted in long-term patency. The unique feature of this case is the intraoperative placement of the stent via the inferior mesenteric vein under fluoroscopic guidance. The use of a large caliber (16 mm) stent obviated the need for postoperative anticoagulation.
Assuntos
Transplante de Fígado/efeitos adversos , Veia Porta , Complicações Pós-Operatórias/cirurgia , Stents , Trombose/cirurgia , Adulto , Feminino , HumanosRESUMO
BACKGROUND: Measurement of panel-reactive antibody (PRA) with an enzyme-linked immunosorbent assay using soluble HLA class I molecules (PRA-STAT) in adult renal transplant recipients predicted graft loss and rejection. We sought to confirm this finding in pediatric recipients, an immunologically distinct group. METHODS: The population consisted of 158 renal transplants in 146 patients (age range, 1-21 years). PRA was determined with PRA-STAT and microlymphocytotoxicity (CDC), using final cross-match sera. An elevated test was defined as > or =5% reactivity. Statistical analysis for rejection used the chi-square test and for graft survival used the log-rank test. RESULTS: Thirty-five patients (22%) had %PRA-STAT > or =5%, compared with 26 (16%) with %PRA-CDC > or =5%. The percentage with elevated %PRA-STAT was found to correlate with subsequent transplantations (first, 15%; second, 67%; third, 75%). Subsequent analyses utilized only the 136 primary recipients, of whom 20 (15%) had %PRA-STAT > or =5% and 16 (12%) had %PRA-CDC > or =5%. Elevated %PRA-STAT correlated with rejection at 3 months (65% vs. 36%), 12 months (84% vs. 50%), and 24 months (84% vs. 54%) (P<0.05). No association was found between elevated %PRA-CDC and rejection. Patients with %PRA-STAT > or =5% vs. %PRA-STAT <5% had graft survival at 1 year of 89% vs. 84%, at 2 years of 88% vs. 77%, and at 3 years of 61% vs. 72% (not significant). CONCLUSIONS: Use of %PRA-STAT > or =5% identifies pediatric recipients who are at increased risk for rejection and may benefit from more potent immunosuppression and/or closer monitoring of graft function.
Assuntos
Rejeição de Enxerto/diagnóstico , Isoanticorpos/imunologia , Transplante de Rim/imunologia , Adolescente , Adulto , Criança , Pré-Escolar , Ensaio de Imunoadsorção Enzimática , Feminino , Antígenos de Histocompatibilidade Classe I , Humanos , Imunoglobulina G/imunologia , Lactente , Masculino , Prognóstico , Estudos RetrospectivosRESUMO
PURPOSE: To establish the safety and efficacy of the Arrow Trerotola mechanical percutaneous thrombolytic device (PTD) for restoring patency of thrombosed hemodialysis grafts. MATERIALS AND METHODS: The hindlimb model of dialysis grafts was created in six dogs. Animals had either unilateral (n = 4) or bilateral (n = 2) polytetrafluoroethylene grafts, totaling eight grafts. Grafts were deliberately clotted 48 hours before thrombolysis. Thrombolysis was performed with five different versions of the PTD constructed of stainless steel (n = 12) or nitinol (n = 26) and rotated with use of a hand-held motor drive. After thrombolysis, fistulography was performed. RESULTS: Thirty-eight procedures were performed with the PTD, with 100% success. Thirty-day patency, evaluated in a subset of 15 procedures, was 100%. Complications included a single arterial embolus (2.6%) and eight device breakages (21%, all but two with the stainless steel version); none had any clinical consequences. A final modification of the nitinol device yielded 11 consecutive procedures without further breakage. No residual thrombus occurred in any procedure. Pathologic examination showed no significant injury to the vessels or neointima. CONCLUSION: The PTD is highly effective for mechanical thrombolysis in an animal model of clotted dialysis grafts. Based on this animal model, the device appears safe in its final modified form.
Assuntos
Trombectomia/instrumentação , Ligas , Animais , Derivação Arteriovenosa Cirúrgica/instrumentação , Prótese Vascular , Modelos Animais de Doenças , Cães , Embolia/etiologia , Desenho de Equipamento , Falha de Equipamento , Artéria Femoral/lesões , Artéria Femoral/patologia , Artéria Femoral/cirurgia , Veia Femoral/lesões , Veia Femoral/patologia , Veia Femoral/cirurgia , Teste de Materiais , Politetrafluoretileno , Diálise Renal/instrumentação , Rotação , Segurança , Aço Inoxidável , Trombectomia/efeitos adversos , Trombose/cirurgia , Resultado do Tratamento , Túnica Íntima/lesões , Túnica Íntima/patologia , Grau de Desobstrução VascularAssuntos
Ciclosporina/farmacocinética , Imunossupressores/farmacocinética , Absorção Intestinal , Transplante de Rim/fisiologia , Imunologia de Transplantes , Administração Oral , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Ciclosporina/administração & dosagem , Ciclosporina/uso terapêutico , Feminino , Humanos , Imunossupressores/administração & dosagem , Imunossupressores/uso terapêutico , Transplante de Rim/imunologia , Masculino , Taxa de Depuração Metabólica , Pessoa de Meia-Idade , Análise de RegressãoRESUMO
A five year retrospective review was undertaken to evaluate the patency rates of arteriovenous fistulae (AVF) in patients with end stage renal disease. From July 1989 through June 1994, 150 fistulae were created in the wrists of 144 patients. Thirty-four percent of the patients had diabetes mellitus. Patient death or irreparable fistulae were considered end points in the study. Patency rates were calculated by the Kaplan-Meier Actuarial Analysis. An analysis to assess the impact of the demographic characteristics, underlying renal disease, and effect of revisions on patency rates was calculated. The results demonstrate a high initial failure rate (less than 1 month) of 13 per cent in the entire cohort undergoing fistulae replacement. The 1 and 5-year patency rates were 56 per cent and 30 per cent, respectively. Diabetics had a significantly lower patency rate at 1 and 5 years (42% and 18%) respectively. Others, who had poor patency rates, include patients 70 years old or greater (40% patency at one year). The results suggest that the AVF should not be the first choice of access in elderly diabetics and that these patients would be better served with other modes of access, such as synthetic conduits or permanent indwelling venous catheters.