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J J Curtis

Publications and source records attributed to J J Curtis.

At least 73 records · Page 4Linked to original sources
PubMed1994

Clinical documentation of end-stage renal disease due to hypertension.

Hypertensive end-stage renal disease (ESRD) purportedly accounts for 25% of new ESRD patients each year in the United States, but remains poorly understood. Clinical features include normal renal function at diagnosis of hypertension, family history of hypertension, left ventricular hypertrophy, and minimal proteinuria. We evaluated clinical and historic data documenting the diagnosis of hypertensive ESRD in 43 patients with ESRD attributed to hypertension who were referred to our center for renal transplantation. Hypertensive ESRD patients were more likely to be black patients with left ventricular hypertrophy compared with our overall population. Few of the hypertensive ESRD patients had undergone kidney biopsy, none of whom had classic features of benign nephrosclerosis. Less than 5% of patients had hypertension documented at any time with normal renal function. Based on our review, it is clearly possible that the number of patients reaching dialysis and transplantation with renal failure attributed to hypertensive ESRD may be overestimated.

Adult↗
PubMed1994

Posttransplant erythrocytosis: an enigma revisited.

Posttransplant erythrocytosis (PTE) is an often-recognized but poorly understood complication of renal transplantation. Defined as a persistently elevated hematocrit (> 0.51), it occurs most commonly during the first 2 years posttransplant in hypertensive males with excellent allograft function. Its consequences are disputed, but may include increased risk of thromboembolic events. Traditionally, PTE has been thought to reflect excess erythropoietin production, of either native kidney or allograft origin, and to abate spontaneously with time. More recent data indicate that factors other than erythropoietin may be involved in the pathogenesis of PTE and that spontaneous resolution is relatively uncommon. Standard treatments have included serial phlebotomy and native kidney nephrectomy. It now appears that PTE also can be managed safely and effectively with converting enzyme inhibitors, a development that challenges our previous understanding of PTE and offers new avenues for investigating its pathogenesis.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1994

Hypertension following kidney transplantation.

Patients often have hypertension after successful kidney transplantation. In the long term, this hypertension adds to patient mortality and morbidity. The widespread use of cyclosporine appears to have changed the nature of posttransplantation hypertension. In humans, cyclosporine-associated hypertension seems to involve sodium retention and stimulation of the sympathetic nervous system.

Animals↗
PubMed1994

Erythropoiesis after withdrawal of enalapril in post-transplant erythrocytosis.

Enalapril effectively decreases hematocrits in patients with postrenal transplant erythrocytosis (PTE). We studied the effect of enalapril withdrawal on erythropoiesis in 18 patients with PTE who had been treated for 13 +/- 8 months. Hematocrit, reticulocyte count, plasma erythropoietin, and plasma insulin-like growth factor I were measured biweekly for six weeks. Red cell mass, plasma volume, transferrin saturation, and plasma angiotensin II were measured at withdrawal and six weeks later. Hematocrit increased by at least 0.04 in 13 patients ('responders') but changed by -0.08 to 0.01 in five patients ('nonresponders'). In the responder subgroup, hematocrit increased from 0.43 +/- 0.05 to 0.51 +/- 0.05 (P < 0.001), red cell mass increased from 25.4 +/- 5.9 to 28.9 +/- 5.9 ml/kg body weight (P < 0.001), and transferrin saturation decreased from 41 +/- 16 to 27 +/- 9 percent (P < 0.01). Reticulocyte count increased two weeks after withdrawal of enalapril. Plasma volume did not change significantly. No measurement changed in the nonresponder subgroup. Plasma levels of erythropoietin, total erythroid stimulating activity, insulin-like growth factor I, and angiotensin II did not change significantly in either subgroup. Enalaprilat did not inhibit erythropoiesis in cell culture. Thus, erythropoiesis increased in 13 of 18 patients after stopping enalapril and was independent of changes in circulating concentrations of several erythropoietic factors, including erythropoietin. The pathogenesis of PTE and mechanism underlying the beneficial effect of angiotensin converting enzyme inhibition remain undetermined.

Blood Proteins↗
PubMed1994

Frequency of seal disruption with the sarns centrifugal pump in postcardiotomy circulatory assist.

We have used the Sarns centrifugal pump for uni- or biventricular assist in 58 patients with postcardiotomy cardiogenic shock. This device utilizes a spinning impeller pump that is magnetically coupled to a motor imparting rotary motion to incoming perfusate. Nine patients (16%) experienced 22 device failures, which consisted of a nonvisible disruption of the seal within the pumphead. This allowed fluid to accumulate between the pumphead and the motor necessitating change of the pumphead. The time to seal disruption was 10-149 h (median 48). Of the 22 seal disruptions, 18 occurred in 73 left ventricular pumps (25%), and 4 occurred in 38 right ventricular pumps (11%) p = 0.015. Left ventricular pumps failed at 10-144 h (median 48), and right ventricular pumps failed at 48-149 h (median 83) p = 0.02. The Sarns centrifugal pump is dependable for its intended use of cardiopulmonary perfusion. However, when used for postcardiotomy assist, seal disruption should be expected. It occurs sooner and is more common during left ventricular assist. We recommend inspection of the magnet chamber for evidence of seal disruption every 12 h with left ventricular assist and every 24 h with right ventricular assist.

Adolescent↗
PubMed1994

Use of a rate-limited ultrafiltration circuit with centrifugal ventricular assist.

Renal insufficiency and pulmonary edema are frequently observed in patients who require centrifugal ventricular assist for postcardiotomy ventricular failure. We describe a technique of using a rate-limited ultrafiltration device in parallel with the assist device circuit to remove excess intravascular volume.

Cardiac Output, Low↗
PubMed1994

Bronchial erosion by an indwelling central venous catheter.

Despite improved technology, central venous catheters are associated with many complications that occur usually within 48 h of placement. We report a 42-year-old man with a rare erosion of a venous catheter (Silastic) into a bronchus 2 years after its insertion.

Adult↗
PubMed1994

Preferential rejection of the kidney in a simultaneous kidney-pancreas transplant.

A case of selective kidney allograft rejection with stable pancreas function in a patient who received simultaneous kidney-pancreas allograft from the same donor is reported. Pancreas function was shown to be normal within the first month posttransplant by both a glucose tolerance test (despite a high corticosteroid dose) and stable urinary amylase values during biopsy-proven acute renal allograft rejection. This patient subsequently rejected his kidney allograft as documented by histopathologic evidence of severe chronic vascular rejection and acute tubulointerstitial rejection, yet his pancreas function remained intact. He subsequently received a six-antigen-matched kidney, continues to have normal fasting glucose and normal glucose tolerance by oral glucose tolerance test, and is without evidence of glucosuria. He has never had a clinical rejection of his pancreas, as evidenced by either a decline in urinary amylase or hyperglycemia, and has not required insulin except in the perioperative period of his second kidney transplant, at which time he was receiving high doses of both corticosteroids and cyclosporin. It is suggested that preferential rejection and subsequent loss of the kidney, although infrequent, do occur in combined renal-pancreas allografts and that maintenance of immunosuppression is justified until retransplant of kidney is available.

Adult↗
PubMed1994

A comparison of patient charges associated with percutaneous transluminal coronary angioplasty and coronary artery bypass grafting.

Appropriate interventional treatment for coronary artery disease is an important component in controlling health care expenditures. We conducted a retrospective study to compare the patient charges associated with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). All patients underwent treatment for left anterior descending coronary artery stenosis over a 3 year 9 month time period from March 1987 to December 1990 and were followed for 7-58 months (median 43 months) after treatment. The two groups were constructed in such a way that they were balanced for common vessels diseased, number of vessels diseased, sex, age, and ejection fraction (EF). The study included 26 PTCA patients between the ages of 33 and 86 years, 18 males and eight females, with a mean EF of 58 per cent, and 26 CABG patients from 39 to 80 years of age, 18 males and 8 females, with a mean EF of 61 per cent. Charges were categorized as to hospital, professional, cardiac medication, follow-up, and total costs. While CABG was initially more expensive, nine of the PTCA patients (38%) required further interventional treatment (3 PTCA, 5 CABG, 1 PTCA and CABG), whereas none of the CABG patients required further intervention (P < .001). This short-term follow-up demonstrated, that although initially less expensive, repeat interventional charges are significantly higher in PTCA patients. With the escalating costs of health care, the appropriate initial interventional therapy for coronary artery disease must be carefully selected to reduce long-term health care expenses.

Adult↗
PubMed1994

Renal retransplantation: the role of race, quadruple immunosuppression, and the flow cytometry cross-match.

To assess the impact of quadruple immunosuppression in black and white recipients of cadaver kidney retransplants, we reviewed data from 178 second or subsequent renal allografts performed at our center between 1985 and 1991. Sixty-six black and 102 white recipients were divided into 3 groups: groups 1 and 2 consisted of patients with a negative complement-dependent cytotoxicity (CDC) T cell cross-match, receiving triple drug therapy (CsA-AZA-prednisone) and quadruple immunosuppressive therapy (quad therapy; Minnesota antilymphoblast globulin-CsA-AZA-prednisone), respectively. Group 3 patients also received quad therapy, but, in addition to a negative CDC cross-match, had a negative T cell flow cytometry cross-match (FCXM). Black and white patients in groups 1 and 2 experienced similar graft survival at 1 year, ranging from 47% to 63% (P = NS). In group 3, 1-year graft survival in whites, but not blacks, improved to 82%, with fewer grafts lost to immunologic causes in the first 90 days after transplant. A parametric analysis of potential risk factors identified a significant effect of better HLA-DR matching (P = 0.0005) on improved graft survival, with previous mismatched antigens (P = 0.04), female donor (P = 0.002), and short duration of previous graft (P = 0.05) as risk factors for graft loss. Race and immunosuppressive protocol did not affect graft survival. In group 3, blacks received fewer well-matched kidneys than whites (P = 0.05), which may have contributed to poorer outcomes for black recipients. Nine of 10 patients undergoing retransplantation with a negative CDC cross-match and a positive T cell FCXM suffered graft loss at a median of 26 days after transplant. Thus, quad therapy did not enhance graft survival for either black or white patients undergoing cadaveric retransplantation. Immunologic considerations, including HLA-DR matching and the FCXM, continue to exert a strong influence on outcomes in these high-risk recipients.

Adult↗
PubMed1993

Diagnostic and therapeutic thoracoscopy: lessons from the learning curve.

A variety of video-assisted thoracic operations are being reported with increasing frequency. Problems encountered during the development of this technology have received less attention. During the course of 27 months, 69 consecutive patients underwent minimally invasive procedures at our institution. Conversion to thoracotomy was required in 16 of 49 (33%) patients undergoing diagnostic procedures and 1 of 20 (5%) patients undergoing therapeutic interventions. Fewer complications occurred in those patients with diagnostic procedures (10 of 49, 20%) versus therapeutic interventions (10 of 20, 50%; p = 0.01). Logistic regression analysis showed chronic obstructive pulmonary disease to be an independent risk factor for complications. The mean postoperative stay was 7.9 +/- 6.8 days for diagnostic and 12.8 +/- 9.7 days for therapeutic interventions (p = 0.02). As new technologic improvements were introduced, the mean hospital stay decreased (first 10 months: 14.6 +/- 10.0 days, 10 to 20 months: 9.8 +/- 9.6 days, more than 20 months: 5.2 +/- 3.0 days, p < 0.004). The surgeon's thoracoscopic experience was not as strongly predictive (5 or fewer cases: 8.9 +/- 5.9 days, 6 to 15 cases: 13.1 +/- 12.6 days, more than 15 cases: 5.0 +/- 2.0 days). Although thoracoscopic surgery is promising, the potential for problems requires careful surgical judgment and expertise in dealing with thoracic complications.

Adult↗
PubMed1993

Randomized, prospective comparison of first- and second-generation cephalosporins as infection prophylaxis for cardiac surgery.

Surgical wound infections after cardiovascular surgery may be life threatening and are resource intensive. Second-generation cephalosporins are purported to have a broader antimicrobial spectrum than first-generation cephalosporins and, therefore, may be more efficacious for infection prophylaxis. We have conducted a randomized prospective study of 702 patients undergoing open heart surgery to test the hypothesis that the second-generation cephalosporin, cefuroxime, will be more efficacious for infection prophylaxis than the first-generation cephalosporin, cefazolin. Patients were randomized to receive cefazolin 1 g intravenously every 8 hours for 48 hours begun 1 hour preoperatively plus 1 g after 4 hours of surgery (8 doses, n = 425) or cefuroxime 1.5 g 1 hour prior to surgery plus 1.5 g every 12 hours for 3 additional doses (4 doses, n = 277). Infection was defined as a draining wound with or without a positive culture. There was no difference in the wound infection rate between the groups (p = 0.68). Chest wound infections occurred in 2.1% of patients treated with cefazolin and 2.9% of patients treated with cefuroxime (p = 0.79). The rate of true mediastinitis requiring exploration and drainage was 0.7% in both groups (p = 0.084). Leg infections occurred in 6.6% of cefazolin-treated patients and 5.6% of cefuroxime-treated patients (p = 0.83). The second-generation cephalosporin, cefuroxime, did not reduce the incidence of wound infection when compared with the first-generation cephalosporin, cefazolin. Since institutional antibiotic acquisition and administration costs vary, careful analysis of these factors will allow determination of the most cost-effective infection prophylaxis regimen in cardiac surgery.

Cardiac Surgical Procedures↗
PubMed1993

Tapering or discontinuing cyclosporine for financial reasons--a single-center experience.

In patients with primary cadaveric renal transplants and stable allograft function, we assessed the impact of tapering or discontinuing cyclosporine A (CsA) for financial reasons. Forty-two patients whose CsA was discontinued ("no-dose") and 29 patients whose CsA was tapered to 100 to 150 mg/d ("low-dose"; mean, 1.7 mg/kg/d) were examined. Results were compared with 70 age- and race-matched control patients maintained on at least 200 mg/d of CsA (mean, 3.9 mg/kg/d). Follow-up time for all patients averaged 55 +/- 18 months. Late acute rejection episodes occurred more frequently in no-dose than in low-dose (P = 0.017) or control (P = 0.001) patients. In the no-dose group, blacks experienced a greater number of late acute rejections than whites. These late acute rejections often coincided with the discontinuation of CsA and contributed to an increased rate of allograft loss in blacks in the no-dose group compared with black and white controls (P = 0.011). In contrast, no increase in late acute rejection episodes occurred in blacks tapered to low doses of CsA. Black patients who remained on low doses of CsA also exhibited a trend toward allograft survival that was intermediate between that of control and no-dose patients. In those patients who retained functional allografts, mean serum creatinine concentration did not differ between the study groups at the beginning and end of the follow-up period. These findings support continuance of CsA in black primary cadaveric renal transplant patients, even if dosages must be reduced to 100 to 150 mg/d.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Experience with mycophenolate mofetil (RS61443) in renal transplantation at a single center.

OBJECTIVE: Mycophenolate mofetil (MM) is a new immunosuppressive agent that reversibly inhibits guanine nucleotide synthesis and DNA replication. Its activity is highly selective for T and B lymphocytes. Two open-label multicenter trials of MM in renal transplantation have been performed. This report summarizes the results from one center involved in these two trials. METHODS AND RESULTS: The initial trial of MM was an open-label dose-ranging trial in primary cadaveric renal transplantation. Mycophenolate mofetil was included in the maintenance immunosuppression regimen from the day after transplantation. Of the 21 patients enrolled in this trial, one (5%) was withdrawn for side effects. There was one graft loss due to recurrent renal disease and two patients were withdrawn for difficulty with follow-up. Mean follow-up is 26 months, and patient and graft survival at 2 years are 100 and 95% respectively. The second trial was designed to study the efficacy of mycophenolate in reversing refractory renal allograft rejection. Patients enrolled in the trial had biopsy-proven acute rejection and had previously received at least one course of high-dose corticosteroids and/or OKT3. Of the 26 patients enrolled in this trial, one (4%) was withdrawn for side effects. There were two deaths. Mean follow-up is 20 months, and patient and graft survival at 12 months was 91 and 54%. The incidence of infections in the two groups was 38% and there were no deaths in either group attributable to infection. CONCLUSIONS: The results of these two studies indicate that mycophenolate mofetil could be administered safely to renal allograft recipients for periods up to 2 years. It appears to be effective in reversing acute rejection in a high percentage of patients refractory to other forms of therapy.

Adrenal Cortex Hormones↗
PubMed1993

Clinical experience with the Sarns centrifugal pump.

Since October 1986, we have had experience with 96 Sarns centrifugal pumps in 72 patients (pts). Heparinless left atrial to femoral artery or aorta bypass was used in 14 pts undergoing surgery on the thoracic aorta with 13 survivors (93%). No paraplegia or device-related complications were observed. In 57 patients, the Sarns centrifugal pump was used as a univentricular (27 pts) or biventricular (30 pts) cardiac assist device for postcardiotomy cardiogenic shock. In these patients, cardiac assist duration ranged from 2 to 434 h with a hospital survival rate of 29% in those requiring left ventricular assist and 13% in those requiring biventricular assist. Although complications were ubiquitous in this mortally ill patient population, in 5,235 pump-hours, no pump thrombosis was observed. Hospital survivors followed for 4 months to 6 years have enjoyed an improved functional class. We conclude that the Sarns centrifugal pump is an effective cardiac assist device when used to salvage patients otherwise unweanable from cardiopulmonary bypass. Partial left ventricular bypass using a centrifugal pump has become our procedure of choice for unloading the left ventricle and for maintenance of distal aortic perfusion pressure when performing surgery on the thoracic aorta. This clinical experience with the Sarns centrifugal pump appears to be similar to that reported with other centrifugal assist devices.

Aorta, Thoracic↗