Combined intestine and kidney transplantation in a patient with encapsulating peritoneal sclerosis: case report.

Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication of peritoneal dialysis characterized by fibrosis and calcification of the intestine that, in severe cases, can progress to intestinal failure and total parenteral nutrition dependency. Medical and surgical interventions carry a poor prognosis in these patients. We describe a case of a 36-year-old female with end-stage kidney disease and severe EPS not amenable to surgical intervention who underwent a combined intestinal and kidney transplantation. At 3 years posttransplantation, the patient has normal intestinal and kidney function. This represents, to our knowledge, the first report of severe EPS and end-stage kidney disease treated with a combined transplant.

Beneficial outcomes of a steroid-free regimen with thymoglobulin induction in pancreas-kidney transplantation.

BACKGROUND: Steroid-free immunosuppressive regimens are becoming more common in pancreas transplantation, with persistent concerns regarding its safety and efficacy. METHODS: We performed a retrospective chart review of 87 pancreas transplant recipients-22 simultaneous pancreas-kidney transplants, 48 pancreas-after-kidney transplants, and 17 pancreas transplant alone-who underwent transplantation within the period of January 2000 to November 2006 and who received induction therapy with thymoglobulin followed by maintenance immunosuppression with tacrolimus and mycophenolate mofetil. We compared one group on a steroid-free regimen (n = 25) with another on a steroid-based regimen (n = 62). RESULTS: At 6 months, there was no kidney graft loss and no significant difference between groups (steroid-free vs steroid-based groups) in patient survival (100% vs 96.8%), pancreas graft survival (96.0% vs 93.5%), acute rejection (4.0% vs 11.3%), hospitalization for any cause (60.0% vs 51.6%), infection requiring hospitalization (16.0% vs 32.3%), or incidence of BK viremia (0% vs 3.2%). CMV viremia occurred less in the steroid-free group (0% vs 17.7% in the steroid-based group, P = .024). The estimated glomerular filtration rate (eGFR) at 6 months was higher in the steroid-free group (74.8 vs 55.7 mL/min/1.73 m2 in the steroid-based group, P = .001), with fewer occurrences of a 25% decline in eGFR (33.3% among the steroid-free group vs 61.7% among steroid-based group, P = .019), despite similar average tacrolimus exposure (11.7 +/- 3.7 vs 12.2 +/- 2.7 ng/dL, P = .478). CONCLUSIONS: A steroid-free regimen with thymoglobulin induction followed by tacrolimus and mycophenolate mofetil for maintenance in pancreas transplantation was safe and effective in preventing rejection, with reduced incidence of CMV infection and better-preserved kidney function.

Graft outcomes of living donor renal transplantations in elderly recipients.

BACKGROUND: Despite the ever-lengthening renal transplant waiting lists, without more donors, living donors serve as a treatment option for patients on dialysis. In the past, patients of advanced age were not considered to be candidates for living donor renal transplantation. Therefore, this study sought to analyze whether older age affects the outcome of living donor renal transplantation. METHODS: A total of 527 primary living donor renal transplantations were performed between January 1, 1995 and January 1, 2006. The subjects were divided into 2 subgroups based on patient age at the time of transplantation. The elder group included all recipients at least 60 years vs the control group of younger patients. RESULTS: Significant differences were observed in readmission rate (elder group, 44%; young group, 31.33%; P = .031) and patient survival rate (P < .001). No significant difference was noted in graft survival rate (P = .201), acute rejection rate (elder group, 10.6%; young group, 13.3%; P = .7), serum creatinine level, or length of stay (elder group, 8.51 days; young group, 6.31 days; P = .083). CONCLUSIONS: Our results confirm that elder patients may benefit from living donor renal transplantation.

Prevalence and clinical course of BK virus nephropathy in pancreas after kidney transplant patients.

The influence of BK virus nephropathy (BKVN) in pancreas after kidney (PAK) transplantation is unclear. A retrospective analysis of PAK transplants performed at our center was conducted to determine the impact of BKVN. Among 40 PAK transplants performed using sequential immunosuppression, four patients developed BKVN, as defined by a >20% rise in serum creatinine and BK viremia (BK plasma load >4 log copies/mL), at a median of 19 months following PAK. In all four patients, treatment of BKVN consisted of reduction in tacrolimus, cessation of mycophenolate mofetil, and introduction of leflunomide. With this approach, two patients experienced improvement or stabilization of renal function. The remaining two patients progressed to dialysis dependence despite treatment. Plasma BK load < or =5 log copies/mL was associated with graft preservation. Gender, age, delay between transplants, cumulative Thymoglobulin dose, and type of kidney donor were not associated with BK virus infection. Pancreas graft rejection or dysfunction was not observed with the above immunosuppression modification. Mean amylase and lipase > or =6 months following BKVN treatment remained normal. BKVN is an important cause of kidney allograft loss in PAK patients. Screening and early treatment of BKVN may enable preservation of kidney and pancreas grafts.

Symmetry breakdown in ground state dissociation of HD+

Experimental studies of the dissociation of the electronic ground state of HD+ following ionization of HD by fast proton impact indicate that the H++D(1s) dissociation channel is more likely than the H(1s)+D+ dissociation channel by about 7%. This isotopic symmetry breakdown is due to the finite nuclear mass correction to the Born-Oppenheimer approximation which makes the 1ssigma state 3.7 meV lower than the 2psigma state at the dissociation limit. The measured fractions of the two dissociation channels are in agreement with coupled-channels calculations of 1ssigma to 2psigma transitions.

Nephron-sparing surgery in a renal allograft.

A 48-year-old woman underwent renal transplantation of an organ from a living related donor in 1978. She experienced excellent graft function for 18 years. Recent evaluation for hypertension revealed two large solid masses involving the allograft. Nephron-sparing excision of two renal cell carcinomas was performed with preservation of renal function. Genitourinary malignancies in transplant recipients and partial nephrectomy in renal allografts are reviewed.

Efficacy of multimodality therapy in advanced renal cell carcinoma.

OBJECTIVES: The integration of systemic biologic response modifier (BRM) therapy and surgery to treat metastatic renal cell carcinoma (RCC) is an evolving approach. The purpose of this study was to evaluate the efficacy of this form of multimodality therapy in patients with metastatic RCC. METHODS: Between 1988 and 1996, 14 patients at our institution underwent initial BRM therapy followed by surgical resection of primary and metastatic RCC lesions. Patient records were reviewed to determine the response to BRM therapy, progression-free survival rate, and overall survival rate. The mean follow-up for the entire group was 43.5 months. RESULTS: After BRM therapy, 9 patients manifested an objective response and 5 patients had stable disease. All patients were then rendered disease-free by surgical excision of residual or recurrent metastatic lesions and the primary tumor. The cancer-specific survival rate at 3 years was 81.5%. Currently, 7 patients are alive and disease-free (mean follow-up 41.4 months), 3 patients are alive with recurrent disease (mean survival 48.3 months), 3 patients died of metastatic disease (mean survival 27.9 months), and 1 patient died of an unrelated cause 54.4 months after therapy. CONCLUSIONS: The results of this study suggest that adjunctive surgery after BRM therapy can extend the survival of selected patients with metastatic RCC. Aggressive surgical resection of stable or responding lesions after BRM therapy should be considered in the management of these patients.

Renal cryosurgery: experimental evaluation of treatment parameters.

OBJECTIVES: Cryosurgery represents a minimally invasive alternative for the management of small or equivocal lesions of the kidney. We evaluated the relationship between ultrasonographic appearance and intrarenal temperatures and the effect of renal artery occlusion on the efficacy of the freezing process in a canine model. METHODS: Ten animals were treated with intraparenchymal cryoablative therapy with (n = 5) or without (n = 5) renal artery occlusion using a rapid freeze technique. Intrarenal temperatures were measured 1.0 cm away from the cryoprobe at various times during the freezing process. The distance from the cryoprobe to the ice ball as monitored by ultrasonography was also determined. The contralateral kidney was removed to facilitate studies of renal function and all animals were killed on day 28 for autopsy and histopathologic examination. RESULTS: A target temperature of less than -20 degrees C was achieved 3.1 mm behind the ice ball in all animals tested. The ice ball stabilized at a radius of 16 mm with prolonged treatment, suggesting that multiple probes will be required to treat renal lesions greater than 2.5 cm in diameter. Renal artery occlusion did not significantly alter the freezing process and provided no practical advantage. Renal function remained stable (final serum creatinine level 1.5 mg/dL or less) in all but 1 animal in which an obstructive stricture of the ureteropelvic junction developed. Effective tissue ablation was confirmed at the treatment site in all instances. CONCLUSIONS: Renal cryoablative therapy is a nephron-sparing modality that can be delivered in a safe, efficacious, and reproducible manner. The treatment parameters defined in this study should allow for intelligent patient selection and rational administration of renal cryotherapy.

Prostaglandin E1 attenuation of ischemic renal reperfusion injury in the rat.

BACKGROUND: Prostaglandin E1 (PGE1), a vasodilating prostaglandin, has been shown to protect against renal ischemic-reperfusion injury in acute experiments. The purpose of this study was to determine whether or not delayed administration of PGE1 would also be effective, as it has been suggested to be, in ischemic hepatic injury. STUDY DESIGN: In a chronic model, rats underwent 60 minutes of total renal ischemia followed by either NaCl or PGE1 therapy delivered at either time 0, 30, or 60 minutes after reperfusion. Serum creatinine and renal histology were evaluated for seven days. In an isolated perfused kidney model, kidneys were similarly treated but were removed and perfused in order to measure renal vascular resistance (VR). RESULTS: Prostaglandin E1 administration at time 0 resulted in lower creatinine values when compared with controls at both day 2 (2.1 +/- 0.4 compared with 4.2 +/- 0.9 mg/dL) and day 7 (0.9 +/- 0.1 compared with 2.3 +/- 0.8 mg/dL). Conversely, no improvement was observed when PGE1 was delayed for either 30 or 60 minutes. Renal morphology at seven days was essentially intact in PGE1-treated rats (time 0) whereas changes characteristic of acute tubular necrosis were observed in control kidneys. Ischemia caused a twofold increase in VR compared with nonischemic controls (6.18 +/- 1.12 compared with 3.45 +/- 0.66 mm Hg/mL/min/g at 20 minutes of perfusion). Prostaglandin E1-treated kidneys (time 0) had a VR that was unchanged from that calculated for nonischemic controls (3.28 +/- 0.63 compared with 3.45 +/- 0.66 mm Hg/mL/min/g at 20 minutes). CONCLUSIONS: These data demonstrate that after total renal ischemia, PGE1 administration at reperfusion ameliorates the expected injury, whereas delayed treatment is ineffective. Decreased vascular resistance may be responsible for this protective effect.

Pancreas transplantation: contemporary surgical techniques.

Since its inception more than 30 years ago, vascularized pancreas transplantation has undergone considerable progress. Given the unique complications associated with transplantation of this organ, modifications in surgical technique have been necessary to improve outcomes. As a result of these surgical advances and improvements in organ preservation and immunosuppression, contemporary graft survival rates approach 90% at 1 year. Despite this level of success, the technique of pancreas transplantation remains controversial. Future efforts to reduce morbidity and minimize immunosuppression will enable pancreas transplantation to remain an important therapeutic option for selected patients with type 1 diabetes mellitus.

Comparative evaluation of cine-esophagogram with esophageal manometry in assessing esophageal motility in progressive systemic sclerosis.

BACKGROUND: Esophageal manometry is considered the gold standard in the diagnosis of esophageal motility disorders. Cine-esophagogram using barium is also a good investigation to screen patients for motor disorders of the esophagus. Comparison between these two investigations has not often been reported in patients with progressive systemic sclerosis (PSS). AIM: To determine relative merits of cine-esophagogram and esophageal manometry in detecting esophageal motor dysfunction in PSS patients. METHODS: Thirty-five patients with PSS irrespective of esophageal symptoms underwent esophageal manometry and cine-esophagogram, results and their were compared. RESULTS: Sensitivity and specificity of cine-esophagogram as compared to manometry were 96.1% (95% CI 88.7%-100%) and 55.5% (95% CI 23%-87.9%) respectively. Its positive predictive value was 86%. CONCLUSION: While esophageal manometry can identify esophageal motor disorder in PSS, cine-esophagogram can be resorted to in doubtful situations, for confirmation of diagnosis.

Cellular distribution of hexa and trivalent chromium in Pseudomonas aeruginosa.

Binding of Cr to P. aeruginosa whole cells increased with an increase in positive charge of the chromium complexes used. Distribution of Cr bound from aqueous solutions of potassium dichromate--a Cr(VI) salt and basic chromium sulphate (BCS)--a Cr(III) salt [used for tanning which has 25% of Cr2O3 on weight basis and is of 33% basicity (one hydroxyl/Cr atom)] was more in soluble fraction (protein and nucleic acids) than in insoluble fraction (lipids, polyphosphates, polysaccharides, lipopolysaccharides and mucopeptides). Electron spin resonance spectrum of the cells exposed to hexavalent chromium revealed the presence of Cr(III) ion demonstrating a reduction of the same by the Pseudomoas. The infrared spectra of chromium exposed cell envelopes support that protein carboxylic sites and proteins are involved in binding Cr(III) and predominantly lipids in Cr(VI). Bound chromium could be removed chemically and the cells could then be reused as a biosorbent.

Effect of chromium on growth of Pseudomonas aeruginosa.

Tolerance level to trivalent chromium-Cr(salen)(H2O)2+ and hexavalent chromium-K2Cr2O7 was assessed in P. aeruginosa isolated from tannery effluent soil. It could tolerate 80 and 100 ppm in liquid cultures and up to 100 and 200 ppm in plate count agar in the presence of trivalent and hexavalent chromium respectively. Unadapted cells took a longer time to grow than adapted cells in the presence of K2Cr2O7. Chromium influenced the cellular contents, morphology and respiration of P. aeruginosa. The chosen trivalent salt of chromium was more toxic than the hexavalent one.

Distribution of interstitial cells of Cajal and nitrergic neurons in normal and diabetic human appendix.

The objective of this study was to determine the distribution of enteric nerves and interstitial cells of Cajal (ICC) in the normal human appendix and in type 1 diabetes. Appendixes were collected from patients with type 1 diabetes and from non-diabetic controls. Volumes of nerves and ICC were determined using 3-D reconstruction and neuronal nitric oxide synthase (nNOS) expressing neurons were counted. Enteric ganglia were found in the myenteric plexus region and within the longitudinal muscle. ICC were found throughout the muscle layers. In diabetes, c-Kit positive ICC volumes were significantly reduced as were nNOS expressing neurons. In conclusion, we describe the distribution of ICC and enteric nerves in health and in diabetes. The data also suggest that the human appendix, a readily available source of human tissue, may be useful model for the study of motility disorders.

Donor kidney volume and outcomes following live donor kidney transplantation.

Pre-donation kidney volume and function may be crucial factors in determining graft outcomes in kidney transplant recipients. We measured living donor kidney volumes by 3D helical computed tomography scanning and glomerular filtration rate (GFR) by (125)I-iothalamate clearances in 119 donors, and correlated these values with graft function and incidence of acute rejection at 2 years post-transplantation. Kidney volume strongly correlated with GFR (Pearson r= 0.71, p < 0.001). Body size and male gender were independent correlates of larger kidney volumes, and body size and age were predictors of kidney function. The effects of transplanted kidney volume on graft outcome were studied in 104 donor-recipient pairs. A transplanted kidney volume greater than 120 cc/1.73 m(2) was independently associated with better estimated GFR at 2 years post-transplant when compared to recipients of lower transplanted kidney volumes (64 +/- 19 vs. 48 +/- 14 mL/min/1.73 m(2), p < 0.001). Moreover, recipients of lower volumes had a higher incidence of acute cellular rejection (16% vs. 3.7%, p = 0.046). In conclusion, kidney volume strongly correlates with function in living kidney donors and is an independent determinant of post-transplant graft outcome. The findings suggest that (1) transplantation of larger kidneys confers an outcome advantage and (2) larger kidneys should be preferred when selecting from otherwise similar living donors.

Endoscopic urethroplasty: an alternative to surgical reconstruction for complete urethral obliteration.

Urethral obliteration is an uncommon complication of urethral injury and is usually associated with pelvic fracture. Until recently, surgical reconstruction was the only means available to restore urethral continuity. Although formal urethroplasty may be associated with excellent success rates, impotence and incontinence are potential complications. Endoscopic urethroplasty has recently evolved into a suitable alternative to surgical reconstruction in selected cases. We review here the technique of endoscopic urethroplasty and include our initial results.

Long-term radiographic and functional outcome of extracorporeal shock wave lithotripsy induced perirenal hematomas.

PURPOSE: We determined the long-term radiographic and functional outcome of extracorporeal shock wave lithotripsy (ESWL) related perirenal hematomas. MATERIALS AND METHODS: We followed 19 patients with 21 ESWL induced hematomas for 4 to 61 months (mean 19.6) after ESWL with serial ultrasound, blood pressure and serum creatinine determinations. RESULTS: Complete radiographic resolution of the hematoma was evident in 18 cases (85.7%), while 2 (9.5%) were significantly smaller and 1 (4.8%) remained unchanged. Of 10 patients who were normotensive before ESWL none experienced sustained new onset hypertension. Of 9 patients with preexisting hypertension none had a sustained exacerbation. Finally, during followup serum creatinine levels overall remained unchanged from pre-ESWL values. CONCLUSIONS: We conclude that, by far, the most likely outcome for patients with ESWL related hematomas is spontaneous radiographic resolution within 2 years without clinically evident adverse effects on blood pressure or renal function.