A dangerous error in the dilution of 25 percent albumin.
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Aged↗
Biomedical subjects
D R Steinmuller
Publications and source records attributed to D R Steinmuller.
Treatment of organic impotence with penile prosthesis in renal transplant patients.
Seven patients were identified who underwent both renal transplantation and penile prosthesis implantation at our institution between June 1980 and June 1990, and their charts were retrospectively reviewed. A total of nine penile prostheses were placed in these patients, five prior to transplantation and four following transplantation. One patient received two prostheses prior to transplantation. One patient received a prosthesis both before and after transplantation. No complications were seen in the four prostheses placed following transplantation with a follow-up of one to forty months (mean 18 months). Of the five prostheses placed prior to transplantation, two were removed due to periprosthetic infections, a cylinder leak developed in one, and one was complicated by penile and scrotal erythema with sepsis.
Adult↗
Impact of obesity on renal transplantation.
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Body Mass Index↗
A single-center experience with shared six-antigen-matched cadaver renal transplants.
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Adult↗
Pericarditis following renal transplantation.
We analyzed data on renal allograft recipients over a 27-year period in order to investigate the frequency, etiology, and outcome of pericarditis developing during the first two months following renal transplantation. Of the 1497 patients receiving renal transplants between 1963 and 1990, 34 patients developed 36 episodes of pericarditis and/or pericardial effusions, for an overall incidence of 2.4%. Pericarditis was attributed to uremia in 14 episodes, cytomegalovirus infection in three, both uremia and CMV infection in four, nonspecific bacterial infection in three, and tuberculosis and minoxidil therapy in one episode each. No etiologic diagnosis could be established in 10 episodes. No statistically significant differences were found between pericarditis and case-matched control patients considering demographic features, the number of immediately functioning grafts, the duration of posttransplant acute renal failure, the number of supportive dialysis days, pre- and postoperative CMV status of the patients, and pretransplant BUN and serum creatinine levels. There were more uremic-related complications (pulmonary edema, gastrointestinal bleeding, central nervous system symptoms) in the pericarditis group. Five allografts in the pericarditis group never functioned, versus only one in the control group. Three patients with pericarditis developed pericardial tamponade. Early diagnosis, close follow-up, and in the case of cardiac tamponade early invasive treatment, should improve the prognosis of this potentially life-threatening complication.
Adolescent↗
Comparison of OKT3 with ALG for prophylaxis for patients with acute renal failure after cadaveric renal transplantation.
A randomized, prospective comparison of OKT3 vs. ALG (University of Minnesota) was performed in patients who had acute renal failure after a cadaver renal transplantation. Criteria for admission to the study were oliguria or increasing serum creatinine in the first 12 hr after renal transplantation. ALG or OKT3 was administered after randomization beginning 12-36 hours posttransplantation. There were no significant differences in age, sex, original disease, ischemia time, or HLA matching between groups. Graft survivals at 1 and 6 months were 84% and 84%, respectively for the ALG group. One- and 6-month graft survival for the OKT3 group was 88% and 84%, respectively. These differences were not statistically significant. The number of rejection episodes and the number of patients with rejection episodes were greater, and the time to first rejection was shorter in the OKT3 group compared with the ALG group, although none of these differences reached statistical significance. There were significantly less side effects in the ALG group compared with the OKT3 group (P less than .05). The greatest reductions in side effects were in fever and hypotension. Patients were monitored with flow cytometry analysis measuring the number of CD2 (T11) and CD3 (T3) cells to adjust the dose of both OKT3 and ALG. Starting doses were 10 mg/kg/day of ALG and 5 mg/day of OKT3. There were no significant differences in the incidence of infections (viral or bacterial) between the two groups. There were no rejection episodes during the prophylactic therapy with either ALG or OKT3. In summary, both ALG and OKT3 provided effective prophylaxis for patients with acute renal failure after renal transplantation. OKT3 was associated with a statistically significant increase in incidence of symptomatic side effects.
Acute Kidney Injury↗
The development of proteinuria and focal-segmental glomerulosclerosis in recipients of pediatric donor kidneys.
Several reports in animals, and sporadic case reports in humans, have suggested that kidneys with decreased nephron mass may be more susceptible to the development of focal-segmental glomerosclerosis. This prompted a reexamination of our previously reported group of pediatric donor-adult recipient renal transplant combinations. Data were analyzed from 31 adult recipients who had received renal transplants from cadaver pediatric donors (less than 6 years) with graft function for greater than 6 months and no evidence of chronic rejection. These were compared with a control group transplanted during the same period with adult donor kidneys. Immunosuppression consisted of azathioprine/prednisone or quadruple therapy in 16 and 15 patients respectively. End-stage renal disease (ESRD) was secondary to chronic glomerulonephritis (n = 9), diabetes mellitus (n = 6), polycystic kidney disease (n = 5), and miscellaneous causes (n = 11). Twenty patients had radiographic documentation of renal hypertrophy posttransplant. All patients had serial 24-hr urinalysis for protein and creatinine after transplantation during periods of stable renal function. Ten patients had renal biopsies performed at a mean time from transplant to biopsy of 10.4 +/- 1.6 months. Seven recipients had biopsies that revealed glomerulosclerosis at 13 +/- 6 months posttransplant. Protein excretion and serum creatinine in these patients were significantly higher than in control patients (1.6 +/- 0.37 vs. 0.49 +/- 0.15 g/24 hr and 1.96 +/- 0.11 vs. 1.64 +/- 0.09 mg%; P less than 0.03 and P less than 0.01, respectively). Only 3 of 25 control adult donor recipients developed proteinuria greater than 0.8 g/24 hr within 2 years of transplantation vs. 15/31 pediatric donor recipients. No correlations with the etiology of ESRD, age (greater than or less than 40 years), weight, sex, diabetes, hypertension, or the number of acute rejection episodes could be found. Our data suggest that adult recipients of pediatric donor renal transplants may be at greater risk for the development of glomerulosclerosis than those recipients receiving adult donor kidneys.
Adult↗
Results with shared, six-HLA-antigen-matched cadaver renal transplants.
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Cadaver↗
Outcome of renal transplantation in patients with a functioning graft for 20 years or more.
In the present study long-term morbidity, quality of life and over-all rehabilitation were assessed in 14 patients with a functioning renal allograft for 20 years or longer. Followup ranged from 20 to 27 years (mean 22.5 years). All patients enjoyed excellent and stable renal function, and the mean serum creatinine level at 20 years was 1.3 mg. per dl. Complications related to long-term immunosuppressive therapy comprised infection in 8 patients (57%), malignancy in 7 (50%), cardiovascular disease in 6 (43%), cataracts in 3 (21%) and avascular necrosis of the hip in 2 (14%). Over-all quality of life was excellent in 13 patients who were able to return to work, participate in pre-illness levels of activity and enjoy sexual activity. While successful renal transplantation allows patients with end stage renal failure to resume relatively normal lives, these patients remain prone to complications resulting from long-term immunosuppressive therapy.
Aged↗
Sexuality, fertility, and renal transplantation: a survey of survivors.
A questionnaire on sexual function and fertility was completed by 54 men and 36 women, at an average of 3 years after successful renal transplant. Sexual desire increased significantly compared to reports of levels 6 months pretransplant. Men also had improved erectile function and ability to reach noncoital orgasms. About a quarter of men and women remained sexually dysfunctional, however. The frequency of sexual activity and overall sexual satisfaction did not improve significantly. Marital status and satisfaction were in the normal range for this group, except that those who became ill before adulthood were less likely to have married or have had children. Infertility was a major concern for 10% of the sample. Regular menstrual cycles were present in 64% of women under age 50, representing a significant improvement after transplantation. Three men fathered a child and two women became pregnant after transplantation. Most patients wanted more information on sexuality, fertility, and renal disease.
Adult↗
Intravenous immunoglobulin infusions for the prophylaxis of secondary cytomegalovirus infection.
Previous studies have shown a benefit of intravenous immunoglobulin infusions for the prophylaxis of primary CMV infections in renal transplant recipients. This study was undertaken in order to see if high-risk renal transplant patients at risk for secondary CMV infection would benefit from prophylactic intravenous immunoglobulin infusions. A randomized prospective study of renal transplant recipients who were considered at high risk for secondary CMV infection was performed. Thirty-four patients were studied, 16 receiving the intravenous immunoglobulin infusions and 18 being untreated controls. Unselected lots of Sandoglobulin (Sandoz) were used for the treatment group (500 mg/kg x 3 doses, followed by 250 mg/kg x 2 doses at 2-week intervals). The number of days febrile and days hospitalized secondary to CMV illness, and the number of complications secondary to CMV illness, were significantly reduced in the patients who were prophylactically treated with intravenous immunoglobulin infusions. None of the patients died from CMV infection in either group. There were no significant complications related to the intravenous immunoglobulin infusions. This study suggests that prophylactic immunoglobulin infusions will reduce the severity of CMV infection in the patient who is at risk for secondary or reactivation infection as well as the patient at risk for primary infection. This therapy should be considered for renal transplant recipients who are at high risk for developing CMV infection, both primary and secondary.
Adult↗
Ineffectiveness of dipyridamole SPECT thallium imaging as a screening technique for coronary artery disease in patients with end-stage renal failure.
The efficacy of dipyridamole single photon emission computed tomography (SPECT) thallium as a screening test for coronary artery disease (CAD), was studied in 45 patients with end-stage renal failure undergoing evaluation for renal transplantation. Coronary arteriography, dipyridamole SPECT thallium imaging and clinical follow-up were performed in all patients. Nineteen patients (42%) had an obstruction of 50% or more in at least one coronary artery. Fourteen patients had a positive thallium scan, but 7 of these were false-positives (sensitivity 37%, specificity 73%). The sensitivity was considerably lower than that quoted for non-ESRF patients in the literature, and significantly lower than a control group of 19 patients without ESRF having comparable severity and distribution of CAD. Five of the 6 patients who died of cardiac causes over a mean follow-up period of 25 months had normal thallium imaging, but all had significant coronary artery disease at cardiac catheterization. Dipyridamole SPECT thallium imaging has not proved a useful screening test for angiographically significant CAD, and does not predict cardiac prognosis in this population.
Adult↗
The use of duplex Doppler ultrasonography to evaluate renal allograft dysfunction.
This study evaluated the utility of duplex Doppler sonograms (DS) and the resistive index (RI) in the identification and differential diagnosis of various causes of renal allograft dysfunction. The efficacy of DS and RI was studied either during acute episodes of allograft dysfunction or during periodic posttransplantation longitudinal analyses. The unique features of each renal allograft results in poor correlative value for single isolated measurements of RI. We observed that the highest RIs were in ATN and that an RI of 0.9 was not specific for acute vascular rejection. Also, an RI of 0.9 was rare in acute cellular rejection. RI could not distinguish acute rejection, chronic rejection, CsA toxicity, or obstruction, although the mean RI was significantly different from normal in these groups. Serial studies of RI did document a change at the time of a clinical event compared to baseline. It is concluded that RI is not specific to any one clinical entity.
Cyclosporins↗
Conventional immunosuppression after deliberate third party transfusions versus cyclosporine in living related renal transplant recipients.
A total of 93 recipients of either HLA-identical (34) or 1-haplotype matched (59) living related donor renal transplants was assigned prospectively into immunosuppressive treatment groups on the basis of transfusion histories obtained at the initial evaluation for transplantation. Patients who received 0 to 2 third party transfusions were given no further transfusion, and received cyclosporine and prednisone immunosuppression after transplantation (cyclosporine group). Patients who received 3 or 4 third party transfusions were given additional transfusions until 5 had been received, and were managed with azathioprine and prednisone after transplantation (azathioprine group). Patients who already received 5 or more third party transfusions had no additional transfusions and were assigned to the azathioprine group. No patient had a positive crossmatch to the potential donor after initial evaluation and confirmation of a negative crossmatch. The number of rejection episodes per patient after transplantation was significantly higher in the azathioprine group for HLA-identical (p equals 0.001) and 1-haplotype (p equals 0.003) recipients. One-year patient survival rats for the HLA-identical cyclosporine and azathioprine groups were 100 and 94 per cent, respectively, with respective 1-year allograft survivals of 100 and 89 per cent in the 2 groups. In the 1-haplotype group 1-year patient survival rates were 95 and 94 per cent for the cyclosporine and azathioprine groups, respectively; allograft survival was 81 per cent for the cyclosporine group and 91 per cent for the azathioprine group. None of the observed differences in graft or patient survival between the 2 groups was statistically significant. Deliberate third party transfusions with conventional immunosuppression and cyclosporine immunosuppression are effective methods to treat recipients of living related donor renal transplants.
Adult↗
Flank donor nephrectomy: efficacy in the donor and recipient.
Since August 1983, 115 patients have undergone live donor nephrectomy via an extraperitoneal flank approach with rib resection. Over-all hospital stay was short and morbidity was negligible. Early graft function was excellent as determined by urinary output in the first 20 hours postoperatively (mean 6,442 cc) and low nadir serum creatinine (mean 1.57 mg. per dl.). Acute tubular necrosis or urinary fistula developed in 3 kidneys (2.6 per cent). In the entire series, only 1 graft (0.8 per cent) was lost to technical complications. We conclude that an extraperitoneal flank approach to live donor nephrectomy is safe for the donor, and provides a structurally and functionally sound allograft for the recipient.
Adult↗
Renal transplant calculi. A reevaluation of risks and management.
Between January 1977 and March 1988, 10 of 892 renal transplant recipients formed urinary tract calculi posttransplantation. The presenting symptoms were predominantly those of azotemia due to obstruction and/or hematuria. Factors predisposing to stone formation included a reconstructive urologic procedure at the time of transplantation (n = 4) or a surgical complication (n = 4), necessitating the placement of a ureteral stent and/or nephrostomy tube, secondary hyperparathyroidism (n = 5), hyperuricosuria (n = 4), and hypercalciuria (n = 1). Four patients passed their stones spontaneously; 1 patient underwent ureterolithotomy, 3 patients underwent endourologic stone extraction, 1 patient was treated with a combination of surgical and endourologic procedures, and 1 patient underwent extracorporeal shock wave lithotripsy as monotherapy. While the management of these patients can be challenging, awareness of predisposing factors, proper application of all currently available urologic techniques, and attention to certain guidelines of management can aid in minimizing morbidity from this rare urologic complication of renal transplantation.
Adolescent↗
Pretransplant assessment of renal viability by phosphorus-31 magnetic resonance spectroscopy. Clinical experience in 40 recipient patients.
A group of 40 cadaveric kidneys was studied just prior to planned transplantation to further assess the applicability of 31P-MRS in the analysis of clinical renal transplant viability. Renal intracellular high-energy phosphorus metabolites (ATP [or NADP], phosphomonoester [PME] and inorganic phosphate [Pi]) and pH were measured noninvasively with MRS surface coils external to cold storage containers. Pretransplant MRS parameters were correlated with subsequent renal function in recipient patients (measured one week postoperatively by the need of dialysis, drop in serum creatinine, urine output, and 123I or 131I Hippuran assessed renal tubular function). ATP and NADP was detected in eleven kidneys and was significantly (P less than 0.001) associated with the best renal function posttransplantation. These kidneys also had the highest PME/Pi ratios (1.66-0.54), while lower ratios (0.36-0.10) were associated with prolonged acute tubular necrosis. The PME/Pi ratios significantly (P less than 0.0001) correlated with subsequent clinical renal function, whereas cold storage times (37 +/- 10 hr) or intracellular renal pH (6.53-7.91) did not. These preliminary data suggest that MRS is a noninvasive, nondestructive and sterile method for assessing clinical viability during hypothermic storage of human cadaver kidneys and the subsequent recovery of renal function postrenal transplantation.
Adenosine Triphosphate↗
Refractory hypertension after renal transplantation.
Hypertension is a common problem encountered after renal transplantation. Many different mechanisms may be responsible for hypertension in this setting, and therapy will depend upon the mechanism(s) affecting the individual patient. Factors that may cause or aggravate post-transplantation hypertension include renal dysfunction secondary to rejection or other diseases of the transplanted kidney, renin production from the diseased native kidneys if these kidneys have not been surgically removed, extracellular fluid volume expansion, toxic effects of medications used after transplantation, especially cyclosporine and intravenous prednisolone, or primary hypertension in the donor or recipient. Renal artery stenosis may predispose to acute renal failure in the presence of treatment with angiotensin-converting enzyme inhibitors. Severe renal artery stenosis may also lead to refractory salt and water retention and fluid overload with congestive heart failure and hypertension, mediated primarily due to extracellular fluid volume excess. Therapy with percutaneous transluminal renal angioplasty or, as a last resort, surgery, can be successful in controlling these problems.
Adult↗