Neuromuscular changes in uraemic patients treated with diet therapy and haemodialysis after successful renal transplantation.
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Biomedical subjects
Publications and source records attributed to B Kock.
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Renal transplantations were performed over a period of three years to twenty patients with end-stage diabetic nephropathy. Two of the patients were transplanted with kidneys from living donors, others with cadaver kidneys. One year after the transplantation 6 patients out of 12 were alive, after two years one out of four. Graft survival after one year was 4 out of 12, and after two years one out of four patients. Eight patients had died, the primary causes of death having been infection or infarction. Late complications in the form of gangrene occurred in four patients with a functioning transplant. The issue of priority, criteria for selection, and the use of living donors are discussed.
Subtotal parathyroidectomy was performed on 34 patients with severe renal insufficiency. The indications were grave clinical symptoms (pruritus, bone pains and mental disturbances), gastric ulcer and radiological abnormalities (metastatic calcifications, osteoporosis, fractures and subperiostal resorption). The serum calcium level was elevated in eight cases. The serum parathormone value was determined in 13 cases, it was elevated in all cases. Less than 500 mg tissue was removed in 12, between 500 and 6000 mg in 19 and over 6000 mg in 3 cases. Nodular hyperplasia was demonstrated in 11 and diffuse hyperplasia in 23 patients. The serum calcium and parathormone levels fell markedly after the operation, and pruritus, bone pains and mental disturbances were markedly alleviated. Complete recovery was achieved only by a successful renal transplantation, but the operation had often a favourable effect on the grave symptoms.
Stenosis of the renal artery of the transplant (RAT), is reported with a frequency of 5-10% (Nerstrøm, Ladefoged & Lund 1972, Nilsson, Henriksson & Thoren 1976, Beachley, Pierce, Boykin & Lee 1976). The stenosis is significant if it deteriorates the renal function or elevates the arterial blood pressure. The angiographic impression of a stenosis depends on the projection and it is difficult to correlate the radiological findings with the blood flow. Moreover both renal failure and hypertension might depend on other factors than stenosis of the RAT. The aim of this study was to establish how often a reconstruction of a RAT suspected of being stenotic would benefit the patient.
During the period Feb. 1967--Aug. 1976 94 first renal transplantations were performed using living related donors and histocompatibility tests. Eight transplantations were performed on children under 15 years old and four on patients over 50 years old. The rest of the patients were between 15 and 50 years old. No exclusions were performed. 22 patients expired, seven of these with a well functioning graft. The patient survival (P.S.) was 90% at 1 year, 87% at 2 years and 77% at 5 years, the graft survival (G.S.) was 81% at 1 year, 80% at 2 years and 68% at 5 years. The clinical results showed a fairly good correlation with the histocompatibility degree. In the A-B-match groups the 1, 2 resp. 5 years P.S. was 95, 96 resp. 89% and G.S. 90, 90 resp. 89%. In 43% of the patients rejection of variable degree developed. The rejection led to graft loss in 12%.
The influence of blood transfusions prior to kidney transplantation on graft survival was analyzed in a series of 406 first transplantations, including 321 necro-kidneys. Among the 131 females with necrokidneys, 14 had not been pregnant or received transfusions, neither had 70 of the 190 male necrokidney recipients been transfused. In comparison with these controls, a slightly better graft survival was observed in the "immune-triggered" patients, especially in those with no detectable lymphocytotoxic antibodies before transplantation, and more markedly in female than in male patients. The effect of pregnancies seemed the same as that of transfusions. The age and pretransplantation dialysis treatment of the recipient appeared irrelevant to graft survival. "Immune-triggering" slightly improved graft survival also in the living donor category.
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Pre- and postoperative kidney size and kidney function were studied in 46 living kidney donors aged 20-74 years. Kidney size was measured by planimetry and by estimation of a renal index. Kidney function was assessed by endogenous creatinine clearance and serum creatinine. Planimetry was superior to the renal index for expressing changes in renal size. Compensatory renal hypertrophy took place in donors up to the age of 74, but the greatest changes in renal size were observed in donors of under 40. Total renal function decreased postoperatively to about 77% of the initial level; this change in renal function was inversely correlated with age, but in all subjects studied the function remained within normal limits.
A clinical presentation is made of a 2-3 year follow-up of six cases of acute renal failure that have been reported earlier. The patients had developed transient renal failure after the intermittent administration of rifampicin. The stage of olig-anuria lasted for 1-3 weeks, and five of the patients were treated by hemodialysis. Two of the patients died due to unrelated causes during the follow-up period. The four patients re-examined were clinically cured. Pathologic findings by light microscopy and immunofluorescence at biopsy were scarce. Nothing abnormal was seen by electron microscopy in two of the cases studied. Renal function was normal. In three cases the excretion at 131I-hippuran renography was slightly slowed. Although in the acute stage the renal lesions histologically appeared toxic, evidence suggestive of an immunological mechanism cannot be excluded.
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Electrophysiological methods revealed subclinical neuropathy in 26 workers, exposed from 1 to 17 years to lead and whose blood lead (PbB) values had never exceeded 70mu/100ml, as ascertained by checking the monitor reports of the factory and by careful exposure history. The PbB determinations had been tested repeatedly and had been found valid. The main findings were slowing of the maximal motor conduction velocities of the median and ulnar nerves and particularly the conduction velocity of the slower fibers of the ulnar nerve. Electromyographical abnormalities comprised fibrillations, diminution of the number of motor units on maximal contraction, and an abnormally long duration of the units. Earlier similar measurements from heavily exposed workers had been even more abnormal. Thus, a dose-response relationship exists on a group basis. Since the regular monitoring of PbBs in most workers during their entire period of exposure excludes the possibility of a body burden out of proportion to the PbB slight neurological damage is produced at exposures hitherto regarded as quite safe.
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A microangiographic study of 17 rejected and surgically removed human kidney transplants, three transplants removed for other reasons and two adequately perfused and preserved but not transplanted cadaver kidneys was performed. Transplants rejected with acute clinical course showed poor or variable glomerular filling and tapering cortical arteries with no impairment of medullary perfusion, more extensively in those transplants showing poor initial function. Chronic rejection, independent of other parameters showed lack of cortical perfusion, and glomerular filling; impaired perfusion of whole segments, arterial wall narrowing and changes secondary to kidney shrinkage. The radiographic patterns of chronic and acute rejection were distinguishable from each other and from nonrejected specimens.
Plasma renin activity (PRA) was measured in nine renal transplant recipients, seven of which had transplant renal artery stenosis. Surgical correction of the stenosed renal transplant artery was performed in six patients. After corrective surgery of the stenosed artery hypertension (mean arterial pressure before operation 156 mmHg) improved (mean arterial pressure postoperatively 110 mmHg) in four patients with high peripheral PRA (17.3+/-3.9 ng/ml. hr). Two patients, one hypertensive, the other normotensive with low PRA (1.5+/-0.05 ng/ml. hr) had no change in their blood pressure after corrective surgery. In three hypertensive renal transplant recipients the PRA of the venous effluent of the own kidneys and the renal transplant were studied selectively. Selective PRA determinations revealed the source of inappropriate renin secretion offering a basis for surgical management of the assocaited hypertension.