Morbid conditions at death in old men.
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To determine what urinalysis findings are normal in patients maintained on chronic hemodialysis, we have studied the urine in 25 such patients. In end stage renal disease correlation with the original disease is lost, and urine characteristically contains many white blood cells and frequent white blood cell casts; microscopic hematuria is unusual even in patients whose original disease was a proliferative nephritis.
The role of renal biopsy in 46 patients with end stage renal failure was assessed. Renal tissue was obtained by open renal biopsy in 24 patients, by needle biopsy in 5, and at bilateral nephrectomy in 17. In 4 patients the renal biopsy specimens showed advanced changes that could only be diagnosed as "end stage kidney". In 42 patients (91 per cent), a precise renal diagnosis was made. In 20 patients (43 per cent) the prebiopsy clinical impression differed from the histologic diagnosis. In the 29 patients undergoing renal biopsy, minor postoperative morbidity occurred in 5. We conclude that a renal biopsy in patients with end stage renal failure will result in a change in clinical diagnosis in a significant number of patients and can be performed with low morbidity.
Sulfur colloid scanning has been suggested as a means of early detection of renal transplant rejection. Visual interpretation of increased uptake by the allograft as opposed to surrounding pelvic structures was taken to signify rejection. In an attempt to increase the accuracy of these scans we programmed a computer to do differential counts between graft and surrounding pelvis and to then calculate a ratio. Hopefully this mathematical determination of increased uptake would be more accurate. These scans were compared with simultaneously obtained biopsy material. Unfortunately, the false negative and false positive rates were too high to make sulfur colloid useful in predicting graft rejection. Finally, our data showed that an early positive scan did not predict long-term outcome as had been suggested by others.
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Because vertebrobasilar arterial disorders seem to be common in patients with end-stage renal disease, a neuroradiological evaluation of vertebrobasilar circulation is necessary for patients with possible vertebrobasilar insufficiency. In three patients on maintenance hemodialysis, contrast-enhanced transcranial color-coded real-time sonography (TCCS) through a suboccipital window delineated occlusion of bilateral vertebral arteries with reversal of the basilar artery, reversal of the left vertebral artery mimicking left subclavian steal phenomenon, and dolichoectasia of the basilar artery and bilateral vertebral arteries with signals of turbulent flow. TCCS has several advantages over computed tomographic angiography and magnetic resonance angiography, including the direction of blood flow, handy performance even during hemodialysis, and contrast agent free from nephrotoxicity. Thus, TCCS is useful in the evaluation of intracranial circulation in patients with end-stage renal disease.
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