Bruce H. Stewart

Circulating and urinary catecholamines in pheochromocytoma. Diagnostic and pathophysiologic implications.

Three biochemical tests for the diagnosis of pheochromocytoma were evaluated in 24 patients with proved tumors and 40 patients whose clinical picture was suspect but who had no evidence of the disease. Measurement of resting, supine plasma catecholamines (by radioenzymatic assay) was more useful than either 24-hour urinary vanillylmandelic acid (VMA) or metanephrines or both. In only one of 23 patients with pheochromocytoma were plasma catecholamines within the range of those in patients without pheochromocytoma, as compared with urinary VMA in 11 of 22, urinary metanephrines in five of 22 and both metabolites in three of 22. These studies reaffirm the value of plasma catecholamines in the diagnosis of pheochromocytoma and indicate that urinary catecholamine metabolites are less useful. The poor correlation between the height of arterial pressure and circulating levels of catecholamines suggests that the regulation of arterial pressure in pheochromocytoma is complex.

Lymphoceles associated with renal transplantation: Report of 15 cases and review of the literature

Abstract Within a 27 month period (from July 1, 1971 to October 1, 1973), during which 83 renal allotransplantations were performed at the Cleveland Clinic, a lymphocele developed in 15 patients (18.1 per cent). Early clinical symptoms, occurring within 6 weeks after transplantation, were suprapubic or lower abdominal swelling in 14 patients, leg swelling ipsilateral to the allograft in 12, nonpitting edema in the allograft area in 10 and lymph drainage from the wound in 8. An intravenous pyelogram demonstrated a lymphocele in 13 patients from 1 to 34 weeks after transplantation (mean 7.8 weeks), although an earlier suggestion of bladder displacement and deformity was found retrospectively in 5 patients between 1 and 3 weeks after transplantation. Lymphangiograms aided in the diagnosis in nine patients. The major complication of the lymphoceles was obstructive uropathy that developed in nine patients between 2 and 34 weeks after transplantation (mean 10.3 weeks). Lymphoceles mimicked rejection, urine extravasation, pyelonephritis, thrombophlebitis and a seroma, and occurred concurrently with rejection and pyelonephritis. Treatment by external surgical drainage was more effective than aspiration both in resolving the lymphocele and in avoiding infection. Three lymphoceles drained spontaneously 1 to 2 weeks after transplantation, and three are under observation. Chemical and protein analyses were made of the lymphocele fluid obtained from seven patients. Numerous factors may contribute to the formation of a lymphocele by increasing lymph flow. The most prominent factors are the extent of surgical dissection, the occurrence of rejection, and the use of diuretics, large doses of corticosteroids, and anticoagulants. The literature on lymphoceles in renal allograft recipients is reviewed, and pertinent comparisons are made with the more numerous reports of lymphoceles in nontransplant patients.

Differential renal venous renin activity in diagnosis of renovascular hypertension. Review of 29 cases.

Bilateral renal venous renin activity determinations were performed preoperatively in 29 patients with unilateral renal artery disease. After the operations, 19 patients had relief of hypertension and 10 did not. Analysis of the renal venous renin activity data indicated that a value for renin activity (stenotic side) greater or less than 4 ng/ml per 4 hours or renin activity ratio stenotic(S)/nonstenotic(N) greater or less than 1.5 yielded a correct prediction of surgical results in 79 percent and 72 percent of the cases, respectively. The renin activity (stenotic side) greater than 4 ng/ml per 4 hour and renin activity ratio S/N greater than 1.5 combined, as an index of surgical success, yielded a correct prediction in 69 percent of the cases. However, when the renin activity (stenotic side) and renin activity ratio S/N were both increased (indicative of success in 12 of 14 patients) or were both normal (indicative of failure in all 5 patients with this finding) the prognostic index was high (89 percent). When there was a disparity in the two values (as in 10 patients), the prognostic accuracy was uncertain and results unpredictable. The criteria of other investigators for a positive renal venous renin study were reviewed. Reanalysis of these data indicated that the criteria of success as denoted by renin activity ratio S/N greater than 1.5 and elevated renal venous renin activity (stenotic side) compare favorably with those obtained with a ratio of 2.0 or more and elevated renal venous renin activity (stenotic side) in the series reviewed.

ROLE OF SCINTILLATION SCANNING IN DIAGNOSIS OF RENAL TUMORS

An evaluation was made of scintillation scanning in 18 patients suspected of having renal tumors. Neohydrin-Hg/sup 203/ was used in a single intravenous injection of 100 mu C. The method did not differentiate between tumors and cysts, and tumors which did not appreciably replace functioning renal tissue could not be detected. In spite of these limitations, it is of value when used in conjunction with routine excretory urography. (BBB)

Evaluation of intravenous renal arteriography.

In a series of 60 hypertensive patients, intravenous renal arteriography produced arteriograms of diagnostic quality in 74 per cent when the serial filming technic was used, compared with 15 per cent when single, long-exposure films were made. The nephrogram phase yielded important information in all cases. Serious complications have not occurred to date, but the possibility of sudden death in elderly, poor-risk patients should be kept in mind. The technic has proved satisfactory as an outpatient procedure and can be performed without special surgical skills. Serial filming apparatus is necessary for optimal results.