Hemodialysis in diabetics: complications in insulin-dependent patients accepted for renal transplantation.

The hemodialysis complications in 67 insulin-dependent diabetic patients accepted for renal transplantation were compared with those in 67 nondiabetic hemodialysis patients. Eleven of the 67 diabetic patients died before receiving a renal transplant-four of myocardial infarction, three of dialysis-related causes, and four of infections. One of the 67 nondiabetic patients died of infection before transplantation. The diabetic patients experienced more complications on dialysis than did the nondiabetic patients; they were more hypertensive and required more ultrafiltration during dialysis. In addition, the diabetic patients had a higher incidence of hypertensive episodes during dialysis, as well as a high incidence of predialysis hyperglycemia. These findings suggest that diabetic patients with renal failure should be dialyzed more frequently and transplanted as soon as possible in order to decrease the complications associated with hemodialysis.

Hemodialysis in an infant with propoxyphene intoxication.

A 10-month-old infant was treated with intensive supportive care and hemodialysis for severe propoxyphene intoxication. Dialysis clearance studies demonstrated that propoxyphene was removed from the serum at approximately 50% of the rate of blood urea nitrogen removal. Possibly because of tissue binding of the drug, the absolute quantity of propoxyphene removed by dialysis was small. The child survived the acute episode of intoxication but died of pulmonary complications several days later. The role of dialysis in propoxyphene intoxication remains to be established.

Successful renal transplantation in patients with prior history of malignancy.

Eleven selected patients with a history of cancer have received renal transplants. In three patients the malignancies were diagnosed and treated before renal failure developed. Two patients underwent bilateral nephrectomies for the treatment of bilateral renal malignancy. In six patients the malignancy developed while they were uremic, and they received transplants after treatment of the tumor. Recurrent tumor developed in only one of the 11 (9 per cent) patients after receiving the transplant. Thus, patients with a history of malignancy can receive a transplant without accelerating growth of the tumor. We recommend a minimum period of one year between tumor treatment and transplantation to observe for tumor recurrences or metastases. A longer period of observation may be necessary in patients who have tumors with a poorer prognosis.

Etiology and prognosis in acute post-transplant renal failure.

During the last seven years we encountered 117 cases of acute renal failure after 492 renal transplants. The affected patients fall into two general groups that can be broadly identified by an 131I-Hippuran renogram: Those in whom low or no uptake is evident on the renogram (group 1) and those in whom good uptake is evident on the renogram (group 2). Fifty per cent of the patients in group 1 have renal arterial thrombosis or hyperacute rejection. These patients should have a renal arteriogram, and immediate nephrectomy may be necessary. The prognosis in these patients is very grave. In group 2, 89 per cent of the patients have acute tubular necrosis, and they do not differ prognostically from patients who experience immediate renal function. Invasive diagnostic procedures should be avoided in this group because they may increase the mortality rate. We believe that repeated renograms, a reduction in azathioprine dosage and careful dialysis is the only treatment necessary.

115 patients with first cadaver kidney transplants followed two to seven and a half years. A multifactorial analysis.

One hundred fifteen consecutive patients received first transplants from cadaver donors at the University of Minnesota between January 1, 1968, and May 31, 1973. All patients have been followed for at least two years. The two-year survival rate is 70 per cent and the two-year transplant function rate is 58 per cent. Considerable improvement in both patient survival and transplant function has been noted since 1971. The success of transplantation appears to depend to a large degree on the age of the transplant recipient, the number of HLA antigens matched between donor and recipient, and the dose of antilymphoblast globulin (ALG) administered to the recipient during the first two weeks after transplantation. Each of these factors appears to be important even when the other factors are controlled, and when patients with diabetes, suffering technical failure or hyperacute rejection, are excluded. The results utilizing well-matched cadaver kidneys plus large doses of ALG appear to be equivalent to those obtained with the use of mismatched kidneys from relatives, but further analysis will be required to draw a definite conclusion. Patients receiving poorly-matched cadaver kidneys do far less well than patients receiving mismatched related grafts, however, even when ALG is utilized.

Hyperglycemic pseudorejection in the diabetic transplant patient.

Serum creatinine elevation in a stable transplant recipient most often suggests rejection of the transplant and requires further evaluation and management. In our series of juvenile diabetic patients who have received kidney transplants, we frequently have observed creatinine elevations in association with hyperglycemia. Correction of the hyperglycemia resulted in return of serum creatinine to normal levels and no rejection therapy was required. To better define this syndrome, 2,734 paired measurements of blood glucose and serum creatinine were obtained in 52 stable post-transplant diabetic patients. A mean increase in blood glucose of 100 mg. per 100 ml. was found to increase serum creatinine by 0.5 mg. per 100 ml. in these patients (r=0.93; p less than or equal to 0.001). Evidence strongly suggests that the pathogenesis of this phenomenon is not a result of a laboratory artifact due to the technique used to determine serum creatinine. The pathogenesis may be due to the increased serum osmolarity and resulting intracellular dehydration associated with hyperglycemia. Recognition of this syndrome is important to all centers participating in the care and management of the diabetic transplant recipient.

Lethal complications of bilateral nephrectomy and splenectomy in hemodialyzed patients.

Routine bilateral nephrectomy and splenectomy (BNS) in uremic patients before transplantation are relatively safe procedures except when there is pre-existing sepsis, diabetes, or severe hypertension. A review of 421 patients undergoing routine pretransplantation BNS reveals that death before transplantation occurs in two definable groups of patients. In our series, the first group, those with juvenile onset diabetes, have a 15.4 per cent pretransplantation mortality (9.6 per cent operative and 5.8 per cent nonoperative) while being maintained on hemodialysis and awaiting transplantation. The second group, nondiabetic patients with other preoperatively definable risk factors such as severe hypertension and infected kidneys, had a 3.25 per cent pretransplantation mortality (1.9 per cent operative and 1.25 per cent nonoperative) while on hemodialysis. Paradoxically, these same factors are used as absolute criteria for pretransplantation nephrectomy at institutions where this operation is not a routine part of the pretransplantation regimen.

Complications of percutaneous femoral vein catheterizations for hemodialysis.

Five life threatening complications of percutaneous femoral vein catheterization for hemodialysis (Shaldon Technique) are presented. They occurred over a period of five years during which 700 uneventful catheterizations were carried out. In three instances femoroiliac vein thrombosis occurred, and on one occasion this was complicated by pulmonary embolism. In two other instances perforation of the inferior vena cava occurred with profuse bleeding. These complications can be aboided by early removal of the catheters after dialysis and by cautiously manipulating the wireguide when resistance or obstruction is encountered during insertion.

Kidney transplants in patients over 50.

Patients with end-stage renal failure shouldn't be denied the only possibility of cure just because they're old or have other chronic diseases. In this study of 69 patients over age 50-the largest series reported from a single medical center-kidney transplants from related donors had the same high rate of success as in younger patients. Over 80 percent of the patients who received kidneys from their children or siblings are still alive, in contrast to 52 percent of those who had to settle for a cadaver kidney. Infection posed the most serious hazard after surgery. Late complications, particularly hypertension and diabetes, were easily controoled and by no means debilitating. Four of the survivors still need hemodialysis, but over two-thirds have recovered completely.

Combination urea and salicyclic acid ointment nail avulsion in nondystrophic nails: a follow-up observation.

Following the initial report by Farber and South on nonsurgical nail avulsion with urea ointment and their emphasis that the therapy was not helpful in treating nondystrophic nails, we utilized a similar therapy to treat a sixty-seven year old patient who had severe arteriosclerotic cardiovascular disease and relatively nondystrophic but symptomatic large toenail disease. Because their formulation was ineffective on nondystrophic nails, a formulation with an additive, 20 percent urea and 10 percent salicylic acid preparation was used. After a period of two weeks of occlusive paplication, painless nonsurgical avulsion was achieved. Moderate maceration of surrounding skin was temporary and relatively asymptomatic.