Timing of Pregnancy After Kidney Transplantation and Risk of Allograft Failure.

The optimal timing of pregnancy after kidney transplantation remains uncertain. We determined the risk of allograft failure among women who became pregnant within the first 3 posttransplant years. Among 21 814 women aged 15-45 years who received a first kidney-only transplant between 1990 and 2010 captured in the United States Renal Data System, n = 729 pregnancies were identified using Medicare claims. The probability of allograft failure from any cause including death (ACGL) at 1, 3, and 5 years after pregnancy was 9.6%, 25.9%, and 36.6%. In multivariate analyses, pregnancy in the first posttransplant year was associated with an increased risk of ACGL (hazard ratio [HR]: 1.18; 95% confidence interval [CI] 1.00, 1.40) and death censored graft loss (DCGL) (HR:1.25; 95% CI 1.04, 1.50), while pregnancy in the second posttransplant year was associated with an increased risk of DCGL (HR: 1.26; 95% CI 1.06, 1.50). Pregnancy in the third posttransplant year was not associated with an increased risk of ACGL or DCGL. These findings demonstrate a higher incidence of allograft failure after pregnancy than previously reported and that the increased risk of allograft failure extends to pregnancies in the second posttransplant year.

Quantification of the early risk of death in elderly kidney transplant recipients.

To inform decision making regarding transplantation in patients ≥ 65 years, we quantified the early posttransplant risk of death by determining the time to equal risk and equal survival between transplant recipients and wait-listed dialysis patients in the United States between 1995 and 2007 (total n = 25 468). Survival was determined using separate multivariate nonproportional hazards analyses in low-, intermediate- and high-risk cardiovascular risk patients. Compared to wait-listed patients with similar cardiovascular risk, standard criteria (SCD) and expanded criteria (ECD) recipients had a higher risk of death in the perioperative and early-posttransplant period. In contrast, low and intermediate risk living donor (LD) recipients had an immediate survival advantage compared to similar risk wait-listed patients. In all risk groups, transplantation was associated with a long-term survival advantage compared to dialysis, but there were marked differences in time to equal risk of death, and time to equal survival by donor type. For example, survival in high-risk recipients of an LD, SCD and ECD transplant became equal to that in similar risk wait-listed patients 130, 368 and 521 days after transplantation. Early posttransplant mortality risk is eliminated in low- and intermediate-risk patients, and markedly reduced in high-risk patients with LD transplantation.

The survival benefit of kidney transplantation in obese patients.

Obese patients have a decreased risk of death on dialysis but an increased risk of death after transplantation, and may derive a lower survival benefit from transplantation. Using data from the United States between 1995 and 2007 and multivariate non-proportional hazards analyses we determined the relative risk of death in transplant recipients grouped by body mass index (BMI) compared to wait-listed candidates with the same BMI (n = 208 498). One year after transplantation the survival benefit of transplantation varied by BMI: Standard criteria donor transplantation was associated with a 48% reduction in the risk of death in patients with BMI ≥ 40 kg/m(2) but a ≥ 66% reduction in patients with BMI < 40 kg/m2. Living donor transplantation was associated with ≥ 66% reduction in the risk of death in all BMI groups. In sub-group analyses, transplantation from any donor source was associated with a survival benefit in obese patients ≥ 50 years, and diabetic patients, but a survival benefit was not demonstrated in Black patients with BMI ≥ 40 kg/m(2). Although most obese patients selected for transplantation derive a survival benefit, the benefit is lower when BMI is ≥ 40 kg/m(2), and uncertain in Black patients with BMI ≥ 40 kg/m(2).

Income of living kidney donors and the income difference between living kidney donors and their recipients in the United States.

Disincentives for living kidney donation are common but are poorly understood. We studied 54 483 living donor kidney transplants in the United States between 2000 and 2009, limiting to those with valid zip code data to allow determination of median household income by linkage to the 2000 U.S. Census. We then determined the income and income difference of donors and recipients. The median household income in donors and recipients was $46 334 ±$17 350 and $46 439 ±$17 743, respectively. Donation-related expenses consume ≥ 1 month's income in 76% of donors. The mean ± standard deviation income difference between recipients and donors in transplants involving a wealthier recipient was $22 760 ± 14 792 and in 90% of transplants the difference was <$40 000 dollars. The findings suggest that the capacity for donors to absorb the financial consequences of donation, or of recipients to reimburse allowable expenses, is limited. There were few transplants with a large difference in recipient and donor income, suggesting that the scope and value of any payment between donors and recipients is likely to be small. We conclude that most donors and recipients have similar modest incomes, suggesting that the costs of donation are a significant burden in the majority of living donor transplants.

The impact of pancreas transplantation on kidney allograft survival.

Whether pancreas after kidney transplantation (PAK) compromises kidney allograft survival, and what pre-PAK glomerular filtration rate (GFR) should be used to select patients for PAK is unclear. We analyzed all (n = 2776) PAK recipients in the United States between 1989 and 2007 and compared their risk of kidney failure to a comparator group of n = 13 635 young adult diabetic kidney only transplant recipients during the same time after accounting for selection bias by the use of a propensity score for PAK in a multivariate time to event analysis. In a secondary analysis, we determined the association of pre-PAK GFR with subsequent kidney allograft survival. Despite an increased risk of death early after pancreas transplantation, PAK recipients had a decreased long-term risk of kidney allograft failure compared to diabetic kidney only transplant recipients HR = 0.89; 95% CI: [0.78-1.00]; p = 0.05. An association of pre-PAK GFR with kidney survival was not evident until 3 years after pancreas transplantation, and patients with a pre-PAK GFR of 30-39 mL/min still attained 10-year post-PAK kidney survival of 69%. We conclude that PAK is associated with improved kidney allograft survival, and pre-PAK GFR 30-39 mL/min should not preclude PAK. Expanded use of PAK is warranted.

A community-based long-term follow up of women undergoing obstetric fistula repair in rural Ethiopia.

OBJECTIVES: To assess urinary and reproductive health and quality of life following surgical repair of obstetric fistula. DESIGN: Follow-up study. SETTING: A newly established fistula clinic (2004) at Gimbie Adventist Hospital, a 71-bedded district general hospital in West Wollega Zone, in rural Western Ethiopia. POPULATION: Thirty-eight women (86%) of 44 who had undergone fistula repair were identified in their community. METHODS: Community-based structured interviews 14-28 months following fistula repair, using a customised questionnaire addressing urinary health, reproductive health and quality of life. MAIN OUTCOME MEASURES: Urinary health at follow up was assessed as completely dry, stress or urge incontinence, or fistula. King's Health Questionnaire was modified and used for the quality-of-life assessment. RESULTS: At follow up, 21 women (57%) were completely dry, 13 (35%) suffered from stress or urge incontinence and three (8%) had a persistent fistula. Surgery improved quality of life and facilitated social reintegration to a level comparable to that experienced before fistula development for both women who were dry and those with residual incontinence (P = 0.001). For women still suffering from fistula no change was seen (P = 0.1). Four women became pregnant following their surgery, among which there was one maternal death, three stillbirths and one re-occurrence of fistula. CONCLUSION: Community-based, long-term follow up after fistula repair succeeded in Western rural Ethiopia. Despite one-third still suffering stress or urge incontinence, the women reported improved quality of life and social reintegration after fistula closure.

Antihypertensive effects of an aromatase inhibitor in inbred salt-sensitive rats.

Rats susceptible to the hypertensive effect of dietary salt (SS/Jr) have excess urinary 19-nordeoxycorticosterone compared with salt-resistant control rats (SR/Jr). 19-Nordeoxycorticosterone is a hypertensinogenic mineralocorticoid, but whether it contributes to the salt sensitivity of SS/Jr is unknown. This study sought to evaluate the contribution of 19-nordeoxycorticosterone to the salt sensitivity of SS/Jr by lowering its production with an aromatase inhibitor, 10-propargyl-androst-4-ene,3,17-dione (19-acetylenic-androstenedione, 19-AA). This aromatase inhibitor also preferentially inhibits nonaromatizing adrenal 19-hydroxylation, an essential step in the formation of 19-nordeoxycorticosterone. To test this hypothesis, inhibitor (120 mg) or vehicle pellets were implanted into male and female weanling SS/Jr at 42 days of age. A high salt diet (8% NaCl) was started and two additional pellets were implanted at 52 and 62 days of age. Systolic blood pressure was measured in all animals and urinary corticosteroids in males. Compared with vehicle, the inhibitor lowered blood pressure at 50 days of age (when it could first be measured) until 64 days of age in females and 71 days of age in males. Corticosterone and aldosterone levels were not different between 19-AA- and vehicle-treated SS/Jr. 19-Nordeoxycorticosterone levels, however, were mildly reduced with the inhibitor (0.05 less than p less than 0.10). After 28 days of high salt diet all 23 of the 19-AA-treated SS/Jr were alive, whereas almost one half of the control animals had died. These data demonstrate that 19-AA attenuates the hypertension in SS/Jr; this effect may be through reduction in 19-nordeoxycorticosterone production.(ABSTRACT TRUNCATED AT 250 WORDS)

Vesical adenocarcinoma occurring in patient with pelvic lipomatosis.

This is the first case reported of adenocarcinoma of the urinary bladder in a patient with pelvic lipomatosis and cystitis glandularis. The abnormal pelvic fat hampered endoscopic evaluation and transurethral biopsy, confused clinical staging, and complicated preoperative irradiation and cystectomy. The development of adenocarcinoma in this patient indicates the potential for malignant transformation of cystitis glandularis and underscores the necessity for endoscopic follow-up of persons with pelvic lipomatosis.

Retrovesical leiomyoma.

Primary tumors arising in the retrovesical area are rare. We recently treated by primary excision a large retrovesical leiomyoma in a forty-five-year-old man. The smooth muscle nature of the tumor was confirmed by electron microscopy. Recognizing this entity is important, since treatment consists only of surgical removal, and the prognosis should be excellent.

Nephrectomy after transplant failure: current practice and outcomes.

The role of transplant nephrectomy after transplant failure is uncertain. We report the use and consequences of transplant nephrectomy among 19 107 transplant failure patients between 1995 and 2003 in the United States. Among 3707 patients with early transplant failure (graft survival <12 m), nephrectomy was performed in 56%, and was associated with an increased risk of death (HR 1.13, 95% CI 1.01-1.26). In contrast, among 15,400 patients with late transplant failure (graft survival > or =12 m), nephrectomy was performed in 27%, and was associated with a decreased risk of death (HR 0.89, 95% CI 0.83-0.95). In early transplant failure patients, nephrectomy was associated with a lower risk of repeat transplant failure (HR 0.72, 95% CI 0.56-0.94), while among late transplant failure patients; nephrectomy was associated with a higher risk of repeat transplant failure (HR 1.20, 95% CI 1.02-1.41). Definitive conclusions are not possible from this observational study. The role of nephrectomy in the management of dialysis treated transplant failure patients, and the implications of nephrectomy for repeat transplantation should be further studied in prospective studies.

Control of wood dust from horizontal belt sanding.

An auxiliary ventilation system has been developed to reduce the wood dust emission from horizontal belt sanders. This system consists of two devices: a hood and a jet stripper. The hood is a narrow low-volume, high-velocity slot hood located between a belt surface and a worktable; the push device is a jet stripper located inside a driven pulley hood opposite the operator site. In combination with a standard sander hood, both devices significantly reduced the wood dust emission into the workroom. Laboratory data were confirmed by field tests conducted at an oscillating edge belt sander at a wood furniture manufacturing plant. These devices work independently of each other and do not interfere with the operator's sanding activity. They do not require special maintenance and are economically feasible.

Poorly coordinated children: a survey of 95 cases.

Screening of 717 5-year-olds and 757 7-year-olds, found 55 of the former and 77 of the latter possibly to be poorly coordinated. Further diagnostic testing with the McCarthy Motor Scales confirmed the problem in a total of 95 children, a prevalence of 6.4%. Neurological examination showed 43% of the 5-year-olds and 21% of the 7-year-olds to have choreiform movements. Of the total 95, proprioception was abnormal in 40%, but abnormal muscle tone present in only 4%. An increased prevalence of hearing loss and obesity and a history of developmental delays was found. Low birth weights, prematurity, post-maturity and perinatal problems were significantly associated with poor coordination. Socioeconomic status was not a significant factor. The difficulties of testing and measuring poor coordination and the need for more precise measures are discussed. Follow-up of at risk children at age 5 with tests of motor coordination is recommended.

On the meaning of increased fluctuating dental asymmetry: a cross populational study.

Suarez reports a greater magnitude of fluctuating dental asymmetry for Neandertal sample when compared with a sample of modern Ohio whites. He postulates that this greater antimeric variance could be due to a greater degree of inbreeding in the Neandertal populations. In the present investigation, the magnitude of fluctuating dental asymmetry is evaluated for Eskimo and Pueblo populations. These populations were found to exhibit dental variance of equal magnitude to that of the Neandertal population. As these populations are not highly inbred, a stress related mechanism is suggested to explain these observations and the inbreeding hypothesis is rejected. The implications of this mechanism to Brace's Probable Mutation Effect are discussed.

Nitrous oxide control in the dental operatory: auxiliary exhaust and mask leakage, design, and scavenging flow rate as factors.

Two new local exhaust systems, intended primarily to control patient mouth emissions of N2O, were installed in a dental operatory, and resulting exposure concentrations to dental personnel were observed. The exposures were found to be typically unaffected by the presence and operation of these new controls. Laboratory testing on a head form, in conjunction with the operatory observations, established that mask leakage due to poor fit was the primary cause of N2O emissions. An improved mask fit and the addition of a slotted skirt around the outer mask shell individually resulted in greatly reduced leakage rates in the laboratory tests. Also, exhaust systems placed on the chin, on the chest, or in the mouth proved effective in capturing mouth emissions simulated by a breathing machine and head form.

A long-term study of the development of N2O controls at a pediatric dental facility.

A review is given of National Institute for Occupational Safety and Health (NIOSH) efforts to control N2O at a pediatric dental operatory from 1978 to the present. Measurements of N2O concentrations were made on four occasions before and after installation of different controls, using an infrared analyzer. Air velocity and volumetric flow measurements also were taken, Video imaging was done in some cases simultaneously with real-time N2O measurements to correlate work practices with exposure data. An infrared imaging system was used to identify sources of N2O. Critical components of resulting recommendations for control include monitoring of N2O concentrations; use of engineering controls, such as a scavenging mask, an effective dilution ventilation system, and auxiliary exhaust; good work practices; maintenance of the equipment; and worker education. Data presented strongly supports the hypothesis that better implementation of controls leads to reduction of N2O exposures. N2O concentrations were reduced by a factor of 61 from their initial levels. The current NIOSH recommended exposure limit of 25 ppm TWA during the time of N2O administration appears to be achievable.

The efficiency of respiratory filters in a coke oven atmosphere.

Several types of commercially available respiratory filter/sorbent combinations were tested in a coke oven environment. The percent penetration of benzene soluble particulate and benzo(a)pyrene through these filters was determined and was generally found to be less than ten percent. Degradation of filtering efficiency was noted with some types of filters. The use of a sorbent cartridge in conjunction with a covering filter did not significantly change penetration of the contaminants which were measured.

School health and four-year-olds.

The results of comprehensive physical, psychological and developmental assessments of 67 four-year-olds are described. The value of this type of review, and the use of nurses and teachers in preschool medical examinations is discussed.