Living kidney donation: recovery and return to activities of daily living.

To determine donor nephrectomy outcomes, a one page 20-item survey of 42 cases was reviewed, including demographics, intervals to normal activities (e.g., driving a car, returning to work), and an open inquiry about the donation process. Hospital records were also reviewed. Nephrectomy under general anesthesia was through an anterior flank, extra-retroperitoneal approach with postoperative epidural pain control. Early self-care, progressive ambulation, and prescriptive pulmonary care were undertaken to facilitate recovery. Length of stay averaged 3.4 (range 2-8) d, and mean hospitalization charge was $15 169 (range $10 733-S29 579). Thirty-four donors were employed outside the home; 18 (53%) returned to work within 4 wk, and the average duration away from work was 4.6 wk (range 6 d 10 wk). Within 2 wk, 25 (59%) were driving an automobile. Usual activities of daily living were fully performed by all donors at a mean of 4.8 wk (minimum 5 d). Forty respondents would donate again, and one might; one did not respond to this question. None reported intermediate or long-term disabilities and all reported return to their pre-donation level of activity. With the anterior extra-retroperitoneal nephrectomy, most donors were out of the hospital within 4 d, were driving within 2 wk, and returned to gainful employment within 4 wk. Living kidney donation, as viewed by the donors, was a positive experience, which appeared to disrupt their lives minimally.

Living-unrelated kidney donation: a single-center experience.

For 140 consecutive renal transplants performed from January 1995 to October 1997, 25 (18%) were from living-unrelated donors (15 women, 10 men, aged 25-63, mean 43 yr). All donors had pre-transplant imaging evaluation of renal anatomy following renal function assessment (minimal creatinine clearance 75 cm3/min). Admission to the hospital on the day of donation preceded nephrectomy under general anesthesia using an anterior flank, extra-retroperitoneal approach (no rib resection). Post-operative epidural pain control was used for all but 1 donor. The 25 kidney donors were hospitalized for 2 (n = 1), 3 (n = 12), 4 (n = 7), or 5-8 d (n = 5) (average 3.9 d) and had a mean hospitalization charge of $15,501 (range $10,808-$29,579). One intra-operative hemorrhage required transfusion; 1 late neural-related pain syndrome required outpatient wound exploration. Two kidneys were lost: a husband recipient from repetitive acute rejections at 3 months; a friend recipient from chronic rejection at 2.5 yr; both await cadaver transplant. The other 23 kidneys are functioning with a mean serum creatinine of 1.8 (range 1.0-3.3) at 3-36 months (patient survival 100%; graft survival 92%). While most donors were spouses (8 husbands and 10 wives), friends, distant cousins, in-laws, and adoptive relatives did well as donors and recipients. Transplantation may increase by 20% or more at centers which encourage broad application of living donor nephrectomy.

Anterior-retroperitoneal living donor nephrectomy: technique and outcomes.

Of 133 consecutive renal transplants, 61 (46%) were living donor grafts recovered in an anterior-retroperitoneal approach. Donor demographics, operative-anesthetic care, length of stay (LOS), hospital charges, and complications were reviewed with donor and recipient follow-up of 4 to 40 months. Donors included 35 women and 26 men, ages 22 to 61 years (mean, 42.2); thirty-nine were living related and 22 were living unrelated donors. Pretransplant evaluation defined renal anatomy and function (minimal creatinine clearance, 75 cc/minute). Hospital admission occurred the morning of donation. Nephrectomy by the anterior-retroperitoneal approach (no rib resection) was followed by postoperative epidural pain control, early resumption of diet, progressive ambulation, and aggressive pulmonary care. Operating room time door-to-door averaged 2 hours, 43 minutes (range, 1 hour, 45 minutes-3 hours, 55 minutes). Donors were hospitalized for 2 (n = 7), 3 (n = 24), 4 (n = 19), and 5 to 8 (n = 11) days (mean LOS, 3.75; range, 2-8 days). The mean charge for donor hospitalization was $15,329 (range, $10,808-$29,579). One donor required transfusion; another was readmitted for wound drainage and pneumonia treated medically. All donors remain well with normal renal function. One early graft loss (3 days) occurred from arterial intimal dissection; all others gained life-sustaining function. Recipient (98%) and graft (92%) survival was excellent at 4 to 40 months. Anterior-retroperitoneal living donor nephrectomy is safe and effective, permitting hospital LOS of usually <4 days, early recovery, and no lasting complications. Excellent donor and recipient results from this procedure should compel critical assessment of techniques requiring more extensive operative exposure or more costly operating room and hospital approaches to donor surgical management.

Current issues in living donor nephrectomy.

Of 96 consecutive renal transplants in 2 years, 50 (52%) were living donor grafts. Donor demographics, treatment plans, length of stay (LOS), charges, and complications were reviewed. Donors included 27 women and 23 men aged 22 to 61 (mean 42.2) years; 33 were living related and 17 living unrelated donors. Racial distribution included 1 Hispanic, 2 Asian, 8 black, and 39 white donors. Pretransplant evaluation defined renal anatomy and function (minimal creatinine clearance 75 cc/min). Hospital admission occurred the morning of donation. Nephrectomy under general anesthesia entailed an anterior flank, extra-retroperitoneal approach (no rib resection); and postoperative epidural pain control was standard. Progressive early ambulation and pulmonary self-care optimized recovery. The 50 donors were hospitalized for 2 (n = 7), 3 (n = 18), 4 (n = 15), 5 (n = 6), and 6-8 (n = 4) days (mean LOS: 3.74 +/- 0.17, range 2-8 days). The mean charge for donor hospitalization was $15,415 +/- $397 (range $10,808-$29,579). One major intraoperative hemorrhage required transfusion; 1 patient was readmitted for wound drainage and pneumonia treated medically. While 40 of 50 patients (80%) were hospitalized for 4 days or less, there was no readmission because of short hospital stay. One early graft loss (3 days) occurred from technical problems; all others gained excellent life sustaining function. Three additional kidneys failed from rejection, noncompliance, and systemic coagulopathy. One recipient died at 8 months (CVA) with normal renal function. Current strategies for successful living kidney donation are thorough patient and family education, ambulatory preoperative testing, morning of surgery admission, and discharge planning beginning before hospitalization. Excellent outcomes may be accompanied by a brief LOS, epidural pain management, and liberal use of willing and healthy related and unrelated living donors.

Computed tomography and magnetic resonance imaging in the diagnosis of pulmonary thromboembolic disease.

In selected cases CT and MRI may be useful for the evaluation of patients suspected of having central pulmonary emboli. In stable patients MRI appears to be superior to CT because no iodinated contrast medium is required. In evaluating critically ill patients CT is better because of its superior resolution, ability to assess changes in the lung parenchyma, and ease of patient monitoring.

The effects of urethane, sodium monohydrogen arsenate and selenocystine on crossing-over in Drosophila melanogaster.

The effects of 0 - 25 mM urethane, 0 - 50 muM selenocystine and 0 - 100 muM sodium monohydrogen arsenate on marker-exchange frequencies have been studied along a region of the X chromosome of Drosophila melanogaster marked by y, cv, v and f. Clear and consistent effects seen in concentration curves were usually but not always found significant in analyses of variance. Urethane concentration curves rose to a higher level at 0.5 to 3 mM and dropped to control levels between 10 and 25 mM. It is proposed that this reversibility was due to a competition between two categories of lesions mimicking natural recombination sites, those on unpaired regions of the chromosome competing with those on already paired regions for recombination-repair enzymes. Selenocystine affected exchange frequencies mainly toward the ends of the unmarked region, especially y - cv, negatively from 2 to 10 muM and positively above 10 muM. These effects are interpreted as being mediated by selenocystine control over restriction of synaptic pairing to terminal regions, especially y - cv. Interaction between urethane and selenocystine in two-chemical treatments satisfactorily support the above explantations for both the urethane and selenocystine effects. Sodium monohydrogen arsenate effects, tentatively attributed to the arsenate ion, differed markedly from those of the other chemicals: "arsenate" concentration curves for single-exchange classes tended to be broadly convex and those for double-exchange classes concave, while interactions with urethane tended to be synergistic or neutral except in one exchange class (that for single exchange in y - cv). No satisfactory explanation of the arsenate effects has yet been found. At 25 mM only, urethane caused male-specific, 95% pupal mortality.