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Biomedical subjects

L E Ratner

Publications and source records attributed to L E Ratner.

At least 19 recordsLinked to original sources
PubMed1997

Local impact of 1995 changes in the renal transplant allocation system.

In 1995, changes to the United Network for Organ Sharing renal allocation system eliminated points for certain HLA matches, increased points for waiting time and for pediatric patients, and extended the mandatory share rule to include the zero-antigen mismatch. We analyzed data, from the period December 1993 to August 1996, on 393 donors, 348 kidney-only cadaveric transplants, and 615 patients ranked first or second on the allocation lists generated for each donor, to assess the effect of the changes in the point system. There was an appreciable (46%) but not significant increase in the frequency of transplants occurring under the mandatory share rule, with a greater relative increase seen in African-Americans than in Caucasians. Recipients of transplants not falling under the mandatory share rule had an increased average waiting time but no increase in sensitization or HLA mismatch, whereas patients ranked at the top of the allocation list had higher levels of sensitization but no increase in waiting time. There was an appreciable increase in the percentage of transplants occurring in African-Americans. Of the various changes we observed, only those involving the mandatory share rule could be attributed to changes in the allocation system, whereas others paralleled changes in the composition of our local waiting list.

Black People↗
PubMed1997

Laparoscopic assisted live donor nephrectomy--a comparison with the open approach.

Live donor renal transplantation provides significant advantages when compared with cadaveric donor renal transplantation in terms of improved patient and graft survival, a lower incidence of delayed function, and a shorter waiting time. Yet despite these advantages, live donors continue to be an under utilized source of kidneys for transplantation. Disincentives to live donation include the length of hospitalization, postoperative pain, cosmetic concerns, and the prolonged convalescence associated with the donor operation. In many instances minimally invasive video-assisted techniques have proven more efficacious than standard open procedures in terms of patient discomfort, length of hospital stay, cost, and length of time until the patient can return to full activity. Laparoscopic live donor nephrectomies are being performed at our institution in an attempt to make live donation more attractive to the potential donor. The purpose of this study was to retrospectively review the results of laparoscopic live donor nephrectomy (LapNx) and to compare them with those obtained using the standard open approach (OpenNx). Ten consecutive LapNx were performed from February 1995 through April 1996. The control group consisted of the 20 consecutive OpenNx performed at the same institution from January 1991 through January 1995 immediately before the initiation of the LapNx program. Live donors were considered candidates for LapNx if they possessed at least one kidney with normal renal anatomy with single renal vessels and a single ureter. LapNx was safely performed in all cases. No patients required open conversion or blood transfusions. The allograft warm ischemic time for the laparoscopic cases was 4.2+/-1.3 min. All kidneys harvested laparoscopically produced urine on the table immediately upon revascularization. Presently nine of the ten recipients have functioning allografts. At three months posttransplant the calculated recipient creatinine clearances were 67.0+/-11.5 ml/min and 64.8+/-21.4 ml/min for the LapNx and OpenNx groups, respectively (P=NS). The LapNx donors had a significantly decreased estimated blood loss, shorter time until resumption of oral intake, decreased postoperative pain (in terms of decreased analgesic requirements), shorter hospitalization, and a shorter interval until the resumption of full activities (P<0.05 for all). In addition, the LapNx group donors returned to work sooner than the OpenNx group (3.9+/-1.6 wk vs. 6.4+/-3.1 wk, respectively) (P=0.024). Four individuals agreed to donate a kidney only after learning of the availability of the laparoscopic approach. We conclude that laparoscopic live donor nephrectomy is technically feasible. In addition, it may offer significant advantages over the standard open approach in terms of patient comfort and convenience. These advantages may make live donor renal transplantation more attractive to prospective donors. The potential decrease in hospitalization and convalescence may also prove to be financially advantageous. We believe that further careful study of this procedure is warranted.

Adult↗
PubMed1997

Transplantation of single and paired pediatric kidneys into adult recipients.

BACKGROUND: The transplantation of kidneys from cadaveric donors < or = 5 years of age into adult recipients is controversial. The large disparity between donor renal mass and recipient body mass is feared to be problematic. Controversy also exists whether to transplant kidneys from these young donors individually or as a pair into a single recipient. STUDY DESIGN: We retrospectively reviewed our experience from January 1991 to January 1995 with 22 adult renal transplantations using kidneys from cadaveric donors < or = 5 years of age. Ten patients received single allografts. Twelve received organs paired en bloc. Fifty-two adult recipients from cadaveric donors aged 18-55 years served as controls. All patients received cyclosporine-based immunosuppression. Recipient characteristics did not differ significantly between the groups. RESULTS: Actuarial patient and graft survival rates were similar for the two groups. The incidence of urinary complications was higher in the recipients of pediatric kidneys than in the adult-donor group (18.2% versus 3.8%, respectively, p = not significant). No grafts were lost from urinary complications. Renal function, as determined by the calculated creatinine clearance, was significantly greater in the pediatric group (76.1 +/- 4.0 versus 61.4 +/- 23.2 mL/min, p = 0.035) by 6 months after transplantation. Recipients of paired pediatric kidneys initially had better renal function (63.9 +/- 21.4 mL/min) than those receiving single pediatric kidneys (38.2 +/- 11.6 mL/min) (p = 0.004), but by 6 months, no significant difference existed. At 2 years, renal function in the pediatric-donor group remained significantly better than in the adult-donor group. Hematocrit levels as a measure of erythropoiesis were similar for single pediatric, paired pediatric, and adult-donor recipients. CONCLUSIONS: Kidneys from cadaveric donors < or = 5 years of age are suitable for transplantation into adults. Pediatric kidneys provide excellent renal function despite an initially tremendous disparity between renal mass and recipient body mass. Rapid true renal growth probably occurs. No appreciable advantage is achieved by using two pediatric kidneys for a single recipient.

Actuarial Analysis↗
PubMed1997

Functional advantages of laparoscopic live-donor nephrectomy compared with conventional open-donor nephrectomy.

Live-donor kidney transplants accounted for only 27% of all kidney transplants performed in the United States in 1995. Prolonged hospitalization, pain, extended convalescence, and related socioeconomic concerns associated with traditional open-donor nephrectomy surgery may discourage potential donors, contributing to a low percentage of live kidney donors. To remove such disincentives, the laparoscopic live-donor nephrectomy procedure was introduced. In this study, the post-discharge course of 10 laparoscopic nephrectomy donors was compared with that of 27 open nephrectomy donors over the same time period. Laparoscopic nephrectomy donors experienced significantly shorter hospitalizations, less pain, felt able to return to work and normal routines sooner, and needed significantly less assistance during the recuperation period than did open nephrectomy donors. The laparoscopic nephrectomy procedure may decrease many of the concerns of potential donors, thus making live kidney donation more attractive and increasing the kidney supply.

Activities of Daily Living↗
PubMed1997

Laparoscopic cholecystectomy: applicability in the geriatric population.

Elderly patients with cholelithiasis are more likely than nonelderly patients to present with an acute complication of gallstone disease such as acute cholecystitis (AC), gallstone pancreatitis (GSP), or common bile duct stones (CBDS). These acute complications may make laparoscopic cholecystectomy (LC) more hazardous, with a potential increase in perioperative morbidity or need for open conversion. The applicability of LC in the geriatric population is, therefore, unclear. We reviewed 283 consecutive patients undergoing attempted LC. Patients were classified as presenting with complicated (AC, GSP, or CBDS) or uncomplicated gallstone disease. Elderly patients were significantly more likely than younger patients to present with AC (40% versus 18%), GSP (19% versus 6%), and CBDS (21% versus 5%) (all P < 0.05). Elderly patients with chronic, uncomplicated gallstone disease (n = 20) and nonelderly patients with uncomplicated disease (n = 159) had similar open conversion rates (5% and 7%, respectively). In contrast, the open conversion rate in elderly patients with complicated gallstone disease (n = 42) was significantly higher (50%) compared to nonelderly patients with complicated disease (n = 62; rate, 16%; P < 0.05). Perioperative morbidity and length of stay were also significantly increased in the elderly group, primarily due to the high percentage of elderly patients with complicated disease. These results suggest that elderly patients with uncomplicated gallstone disease appear to be excellent candidates for LC, and this should be considered before complicated disease develops. Conversely, early conversion or planned open cholecystectomy may be warranted in the elderly presenting with acute complications of cholelithiasis.

Aged↗
PubMed1996

Double renal allografts successfully increase utilization of kidneys from older donors within a single organ procurement organization.

BACKGROUND: In 1994, a policy of double renal allografting (DUAL) was used at two centers within our local organ procurement organization to increase utilization of kidneys from older donors that would otherwise be discarded. Both kidneys from an older donor (age > 60 years) were selectively transplanted into a single adult recipient. METHODS: The relative impact of a DUAL policy on the utilization of older donor kidneys is examined for the period of April 1994 to April 1996. Actual utilization is compared with the hypothetical case in which a DUAL policy is not present. RESULTS: In the actual setting, a total of 75 kidneys from older donors (> 60 years) were accepted for transplantation. Thirty-six kidneys were transplanted as singlets, and 16 additional kidneys were transplanted as DUAL renal allografts. Thus, a 44% increase in transplantable kidneys, and a 22% increase in patients transplanted with kidneys from older donors, was realized. In the actual setting, 23 older kidneys were discarded; without the DUAL policy, 39 kidneys would have been deemed untransplantable. When compared with the actual (n = 52) and hypothetical number of kidneys transplanted without a policy of DUAL transplantation (n = 36), the DUAL policy significantly increased the utilization of older donor kidneys (P = 0.01). The actuarial 1-year graft survival rate of the dual kidneys was 100%, with a mean follow-up of 11.1 +/- 2.9 months. Mean 6-month and 1-year serum creatinine level were 1.76 +/- 0.4 and 1.63 +/- 0.6 mg/dl, respectively. CONCLUSIONS: A DUAL policy significantly increased the number of older donor kidneys transplanted in a single organ procurement organization and reduced the rate of discard of older donor kidneys over a 2-year period. Long-term follow-up is necessary to substantiate satisfactory graft function in DUAL from older donors.

Age Factors↗
PubMed1996

Transplantation of kidneys from expanded criteria donors.

BACKGROUND: The critical shortage of organs for transplantation has resulted in a controversial expansion of the criteria used to define a suitable cadaveric organ donor. The shortage of kidneys has a particularly hard impact on those patients on the waiting list who have uncommon major histocompatibility antigens or who are highly immunized. METHODS: To determine outcomes between patients receiving grafts from expanded criteria donors (ECDs) and others, a retrospective review of 105 consecutive kidney transplantations performed at a single institution during a 3 1/2 year period was conducted. A total of 44 (41.9%) patients received kidneys from ECDs, 45 (42.9%) from conventional cadaveric donors, and 16 (15.2%) from live donors. All patients were treated by the same physicians and received either triple or quadruple sequential immunosuppressive therapy. In general, high risk recipients did not receive kidneys from ECDs. RESULTS: Actuarial graft survival, incidence of delayed function, length of stay, and hospital charges were not significantly different between the ECD and conventional cadaveric donor groups of recipients. A higher incidence of urinary complications occurred in the ECD group (p=0.03). This incidence was noted primarily in the recipients of kidneys from donors 5 years of age or younger. However, no allografts were lost as a result of urinary complications. ECD kidneys that were imported from outside the local catchment area accounted for approximately 25% of all cadaveric transplantations performed. CONCLUSIONS: With appropriate selection of organs from ECDs, acceptable results can be obtained. ECD organs can serve to partially alleviate the extreme organ shortage. These organs should be procured and made available to those centers willing to use them.

Adult↗
PubMed1996

Outcome following colon surgery in the octagenarian.

The results of colon surgery in all individuals aged 80 years or greater at one teaching institution during the 1987-1993 time period were reviewed. Sixty patients, ranging in age from 80 to 92 years, underwent 41 elective operations and 21 emergency procedures. Emergency procedures resulted in death or a major complication in over one-half of patients, and only six were ultimately able to return home. Conversely, elective procedures were relatively well tolerated, and 31 of 37 survivors returned immediately to independent living (P = 0.006). Mortality was 33.3 per cent in emergency cases versus 9.8 per cent in elective operations (P < 0.03). The occurrence of a postoperative complication increased the length of stay by an average of 12 days. These data suggest that elective colon surgery in the elderly produces results little different from the population at large. Conversely, emergency operations are associated with a high morbidity and mortality rate. Age alone should not be a determining factor in who undergoes an elective colon operation. Greater efforts should be made to screen elderly individuals to limit emergency surgery.

Age Factors↗
PubMed1996

Laparoscopic live donor nephrectomy: the initial 3 cases.

PURPOSE: Successful laparoscopic live donor nephrectomy in 3 patients is described. MATERIALS AND METHODS: The procedures were performed completely laparoscopically and the kidneys were extracted via 8 cm. infraumbilical incisions. RESULTS: In all 3 cases warm ischemic time was less than 5 minutes, and the renal vessels and ureter of the harvested kidneys were of adequate length for routine transplantation. Donors required minimal postoperative parenteral analgesia and were discharged home 1 to 3 days after the procedure. All harvested kidneys were successfully transplanted, and functioned well initially and at hospital discharge. CONCLUSIONS: Laparoscopic live donor nephrectomy may be an alternative surgical modality to conventional open nephrectomy. Advantages include less postoperative pain, shorter hospital stay and convalescence, and a more desirable cosmetic result. Additionally, these advantages may encourage more individuals to consider live donation, resulting in an increase in organ supply.

Adult↗
PubMed1996

Will stereotactic breast biopsy achieve results as good as current techniques?

Stereotactic procedures recently have been advocated to replace most needle localization and open biopsy procedures. In order to provide a baseline for comparison at our institution, a retrospective review of our results over the last 3 years was performed. During this time period, 496 biopsies were performed in 480 patients. Needle localization was done in 311 cases, whereas the remaining 185 biopsies were done for palpable masses. There were no significant differences in either the positive rate (19.0% vs 13.5%) or the infection rate (2.6% vs 1.6%) in the two groups. Follow-up of all patients has revealed no missed carcinomas and no referrals to a plastic surgeon for a poor cosmetic result. Current breast biopsy techniques yield good results, with acceptably low morbidity rates. Given that approximately one in five needle localization biopsies detects a malignancy, a negative result following a stereotactic biopsy may not preclude a needle localization procedure. It is therefore unlikely that stereotactic procedures will lead to an overall decrease in health care costs. Surgeon involvement will be crucial to assure best and most cost-effective results.

Adolescent↗
PubMed1996

Immunohistochemical manifestations of unilateral kidney ischemia.

Events in the early post-transplant period have been correlated with increased renal allograft loss. Immunologic reactions and ischemic injury have been implicated in this process. While the immunologic aspects of allograft injury have been studied extensively, ischemic effects remain less well understood. To study the effects of ischemia in rats with different genetic backgrounds without the introduction of an alloimmune response, a clamp was placed on the vascular pedicle of the left kidney for 60 min. The short-term effects (1 wk) of ischemia were studied in groups of PVG (RT1c), LEW (RT1), DA (RT1a) and WR (RT1u) rats, Immunoperoxidase staining demonstrated limited infiltration of monocytes, macrophages, and T-cells accompanied by upregulation of low levels of MHC class II antigens on tubular epithelial cells, peritubular capillaries, and interstitial cells in kidneys of PVG and WF rats. Kidneys of LEW and DA rats had greater influxes of monocytes, macrophages, and T cells in addition to higher amounts of MHC class II antigens upregulation on tubular epithelium and interstitial cells. The long-term effects of ischemia were studied in kidneys of WF rats. These kidneys had a progressive increase in infiltrating T cells, monocytes, macrophages and MHC class II expression on the tubular epithelium and the interstitial cells at 14, 30, and 90 d after the ischemic insult. The differences in MHC class II expression between ischemic kidneys of PVG and LEW rats were not associated with differences in production of mRNA for IL-2, IFN-gamma, and TNF-alpha. In summary, transient renal ischemia in the absence of an allogeneic immune response triggers a progression of inflammatory responses, including leukocyte infiltration, cytokine production and MHC class II antigen upregulation which appears to be strain-dependent.

Animals↗
PubMed1995

Laparoscopic live donor nephrectomy.

A laparoscopic live-donor nephrectomy was performed on a 40-year-old man. The kidney was removed intact via a 9-cm infraumbilical midline incision. Warm ischemia was limited to less than 5 min. Immediately upon revascularization, the allograft produced urine. By the second postoperative day, the recipient's serum creatinine had decreased to 0.7 mg/dl. The donor's postoperative course was uneventful. He experienced minimal discomfort and was discharged home on the first postoperative day. We conclude that laparoscopic donor nephrectomy is feasible. It can be performed without apparent deleterious effects to either the donor or the recipient. The limited discomfort and rapid convalescence enjoyed by our patient indicate that this technique may prove to be advantageous.

Adult↗
PubMed1995

Cholecystectomy in the peritoneal dialysis patient. Unique advantages to the laparoscopic approach.

Laparoscopic cholecystectomy has proven to be a safe and effective treatment for symptomatic gallstone disease. Several subsets of patients, however, may not be candidates for the laparoscopic approach, including patients with morbid obesity, acute cholecystitis, and previous abdominal surgery. Because of peritoneal thickening and abdominal adhesions secondary to peritoneal dialysis, the applicability of laparoscopic cholecystectomy in patients maintained on chronic peritoneal dialysis is also unclear. We performed laparoscopic cholecystectomy on three peritoneal dialysis patients without intraoperative complications. We have noted several unique advantages to laparoscopic surgery in this patient population and advocate this approach in peritoneal dialysis patients requiring cholecystectomy.

Adult↗
PubMed1995

Acute abdomen in the hemodialysis patient population.

BACKGROUND: The cause and frequency of the acute abdomen in patients undergoing hemodialysis are not well reported. Previous studies associate bowel infarction with hemodialysis, but dialysis generally is not implicated as a risk factor for mesenteric ischemia. METHODS: The records of 567 patients undergoing long-term hemodialysis during the period from July 1988 to June 1993 were retrospectively reviewed. RESULTS: Twelve patients (2.1% of the hemodialysis population) were admitted with acute abdominal pain or sepsis. They were demographically no different than their counterparts who did not have an acute abdomen. The final diagnoses were bowel infarction in 11 patients and acute pancreatitis in one. Principal areas of involvement were equally divided between large and small intestine and were due to nonocclusive mesenteric ischemia in all cases. Six patients had an occluded hemodialysis fistula on admission, suggesting hypotension and/or hypovolemia as a possible etiologic factor. Overall, mortality and major morbidity rates were 50% and 25%, respectively. CONCLUSIONS: An acute abdomen is a relatively uncommon problem in the hemodialysis population but is associated with a high mortality. Mesenteric infarction is the most common cause and should be the presumptive diagnosis until proven otherwise.

Abdomen, Acute↗