Long-term results with forty-five living related renal allograft recipients genotypically identical for HLA.

During the past decade 45 living related renal allografts have been performed between siblings genotypically identical for HLA. In each case all available family members were serotyped and haplotype analysis was performed. Immunosuppressive therapy consisted of standard azathioprine and prednisone regimens. Only one instance of HLA-D incompatibility was documented. HLA-A, -B haplotypes were identical in each case. Histopathological evaluation by light, immunofluorescence, and electron microscopy was completed. Four patients experienced acute cellular rejection with mild long-term impaired renal function. Five patients had acute cellular rejection but subsequently experienced long-term normal renal function. Twenty-three patients had little or no rejection documented and half of these patients are being maintained without steroid therapy. Five patients had histologically proven acute humoral rejection and, of these, three subsequently lost their allografts whereas two regained relatively normal renal function. Recurrent glomerulonephritis was documented in six cases. One was lobular, one crescentic, and one dense-deposit membranoproliferative glomerulonephritis. Three cases of IgA nephropathy were diagnosed. In each case the recurrent glomerulonephritis reflected the same histopathology and clinical course as the disease realized in the host kidneys. Eighty-seven percent of the 40 surviving patients have been rehabilitated completely and are fully employed.

Renal transplantation between HL-A haploidentical donor-recipient pairs: functional and morphological evaluation.

Fifty-nine recipients received renal allografts from an HL-A haploidentical family member. Immunogenicity of the incompatible haplotype was measured by skin grafts exchanged within each family when possible, and renal allograft recipients were assigned prospectively to two groups depending on the skin graft survival time (Group 2A greater than 15 days; Group 2B less than 15 days). If skin grafts could not be accomplished, the patients were place in an unclassified group, Group 2. Renal function at one and 2 years following engraftment did not differ between the two groups. Mixed lymphocyte stimulation of recipient lymphocytes by mitomycin-treated donor lymphocytes also was comparable in the groups. Histopathological evaluation by light, immunofluorescence, and electron microscopy at least 6 months following allografting did not distinguish between the groups. The only differentiating characteristic was that Group 2A patients did not experience their primary rejection episode until an average of 18 days following transplantation, whereas Groups 2B and unclassified 2 had their initial primary rejection episode at average days 9 and 5, respectively. In our clinical program, matching for HL-A halotypes continues to be the best predictor for long-term renal function in consanguineous renal transplantation.

Percutaneous transhepatic ultrasonic cholelithotripsy.

In a patient with acute cholecystitis whose body habitus precluded cholecystectomy, we used percutaneous transhepatic ultrasonic cholelithotripsy. We compare it with other modalities applicable in such cases. Although not commonly used, these alternatives may be the most appropriate therapy in certain unusual circumstances.

Xanthogranulomatous pyelonephritis in renal transplant recipient.

Xanthogranulomatous pyelonephritis is reported in the native kidney of a renal allograft recipient. Immunoglobulin deposition in the transplant kidney in the absence of cell-mediated rejection, accompanied by selective cultures showing Escherichia coli from the native kidney, led to the diagnosis. Native nephrectomy resulted in resolution of the patient's chronic bacteriuria and creatinine elevation.

Results and morbidity of percutaneous nephrolithotripsy.

The medical records of the first 210 patients treated with percutaneous nephrolithotripsy at Duke University Medical Center were reviewed. Eleven patients were treated for bilateral stones for a total of 221 renal units. The procedure failed in 6 patients (2.7%). Stone fragments were retained in 55 patients (24.9%), with unplanned fragments in 41 cases (18.6%). Open surgery was subsequently performed in 4 patients (1.8%). There were no nephrectomies or deaths in our patients. Percutaneous nephrolithotripsy is a highly successful method for removal of upper tract stones and has a complication rate no higher than that of open surgical procedures.

Modified Johnson basket for antegrade stone extraction.

A modification of a classic Johnson stone basket has been made, such that this basket can pass easily over an angiographic guide wire. With this modification, the Johnson stone basket is an excellent instrument for use in an antegrade or a retrograde fashion for retrieving impacted ureteral calculi. Eleven patients had ureteral calculi manipulated. Of the six ureteral calculi manipulated with standard retractable baskets, only three were successfully extracted from impacted positions. Of the five manipulated with the modified Johnson stone basket, however, four were successfully extracted. The modified Johnson stone basket is an essential instrument in percutaneous manipulation of ureteral calculi.

Ureteral obstruction of solitary kidneys by iliac artery aneurysms.

Two patients with solitary kidneys had ureteral obstruction caused by iliac artery aneurysms. Both patients were treated successfully with ureterolysis and temporary proximal diversion. Iliac artery aneurysms generally remain asymptomatic; however, patients may have urologic complaints (such as hematuria, flank pain, anuria, or a pulsatile urinary stream), and severe complications may develop as a result of an obstructive uropathy. Diagnosis is confirmed by cystoscopy when a mass is present, intravenous pyelography, retrograde pyelography, and arteriography. Treatment must be individualized with consideration of the etiology of the aneurysm and condition of the patient. Surgical correction of the aneurysm may be appropriate. Ureterolysis, with proximal diversion as a temporary safety valve, is a useful procedure particularly when the patient has a solitary kidney.

Minimal mortality of renal surgery.

Eight hundred fourteen renal operative procedures were reviewed to determine overall mortality and to identify patients at risk. The over-all mortality was 1.35%, but as high as 30% in patients with uremia and spesis. Carcinomatosis contributed to higher mortality in other groups. In the absence of these three factors renal surgery was associated with very low or no postoperative (thirty day) mortality.

Neonatal female urethral diverticulum.

Urethral diverticula are uncommon, and congenital origin has been disputed. A well-documented case in a six-hour-old baby girl is presented to reinforce the concept of congenital origin in some instances. Surgical diagnosis and management are discussed.

Computerized tomographic diagnosis of massive hydronephrosis of duplicated system in an adult.

A case of massive hydronephrosis of the upper portion of a duplicated collecting system in a middle-aged male is presented. Computerized tomographic examination of the abdomen provided the most precise information and led to a correct preoperative diagnosis, whereas both urography and ultrasound did not.

Blind-ending branches of bifid ureters.

Three new cases are utilized to illustrate the anatomy, embryology, and symptomatology of blind-ending branches of bifid ureters. Diagnosis can usually be made by intravenous pyelogram. The complications are recurrent urinary tract infections, calculi, and hydroureteronephrosis. Selection of management by observation, resection, nephroureterectomy, or ureterolithotomy is discussed. The specific techniqie for simple resection is stressed.

Role of linear tomography in evaluation of patients with nephrolithiasis.

One hundred twenty-four consecutive patients with suspected or known nephrolithiasis were referred for evaluation by linear tomography. Renal calculi were detected in 98 patients (79%). Linear tomography revealed more renal calculi than did preliminary KUB films in 46 patients (37%), although in only 10 cases (8%) was the tomogram positive if the KUB was negative. Exact quantification of the numbers and locations of renal stones is important in patients to be managed metabolically, and in those being evaluated in advance of or following percutaneous or extracorporeal lithotripsy.

Long-term management of vasovasostomy patients.

Follow-up of 54 patients undergoing modified single-layer bilateral vasovasostomies are presented with attention to semen quality, pregnancy rates, and postoperative findings potentially inhibiting fertility. The technical success rate was 98%, but 3-month semen analyses varied from "poor" (less than 20(6)/ml; greater than 50% normal motility) of 20% to "excellent" (greater than 26(6)/ml; greater than 50% normal motility) of 35% without effect on long-term pregnancy rates, 50% and 54.5%, respectively. Other factors, such as sperm clumping, prostatitis, and immunologic interference, appear to decrease motility. Close follow-up with attention to factors affecting fertility other than simple concentration and motility are rewarding.

PIP: Follow-up of 54 patients undergoing modified, single layer bilateral vasovasostomies are presented with attention to semen quality, pregnancy rates, and postoperative findings potentially inhibiting fertility. The technical success rate was 98%, but 3 month semen analyses varied from poor of 20% to excellent of 35% without effect on longterm pregnancy rates, 50% and 54.5%, respectively. Other factors, such as sperm clumping, prostatitis, and immunologic interference, appear to decrease motility. Close follow-up with attention to factors affecting fertility other than simple concentration and motility are rewarding.

Analysis of injury in complex organ preservation.

A biochemical assay of renal viability previously described for rabbits is validated in a canine model using anoxia, hypothermia, and hypothermic perfusion. The assay correlated well with the decree of anoxic injury and protective effect of hypothermia. It was found to be unable to document significant injury when pulsatile perfusion was added to the system and resulted in nonviable canine kidneys. Apparent vascular damage with interstitial hemorrhage occurred after the perfusion and was not predictable by the use of the assay system. The limitations of any assay for organ viability after complex preservation maneuvers is the result of a multiplicity of injurious factors surrounding the preservation or as a consequence of the preservation. No single assay system will be adequate for protection of organ viability during or after preservation as long as the types of injury are multiple. Is is suggested that great care be used in defining possible injurious factors associated with given preservation maneuver and that specific assays be utilized to document the effects of each of these factors. The more complex the preservation system employed; the more complex the assay system needed.

Lessons learned in patients with large steinstrasse.

Experience with 19 patients (25 ureters) who suffered the complication of a large steinstrasse (a third or more of the ureteral length) has led to lessons regarding the management of this complication as well as to insights into patient presentation, metabolic consequences, and the efficiency of diagnostic and therapeutic modalities. Few symptoms were present in a large percentage of patients despite urinary obstruction, decreased renal function, infection and in several cases impending sepsis. Large stone burdens, bilateral treatment, inability to debulk stone burden before extracorporeal shock wave lithotripsy and unexpected fragment movement were definite predisposing factors in the development of this complication. Double pigtail stents and percutaneous nephrostomy alone did not always prevent or resolve the problem. Combined use of percutaneous nephrostomy and ureteroscopic ultrasonic or laser lithotripsy appears to be the most effective treatment modality in patients who fail brief observation. This approach can be combined under appropriate circumstances with a secondary extracorporeal shock wave lithotripsy or percutaneous nephrolithotripsy treatment in the staged management of complex upper urinary tract calculous disease.