Fuad J. Dagher

The use of basilic vein and brachial artery as an A-V fistula for long term hemodialysis

Abstract 1. 1. A new access for long-term hemodialysis has been developed by creating a fistula in the upper arm between the end of the basilic vein and the side of the brachial artery. 2. 2. The operative procedure is simple to carry out, providing a straight, long, easily accessible fistula with high flow. 3. 3. The use of Bovine, saphenous, or prosthetic grafts is avoided, and anatomic continuity at the venous end of the fistula is maintained. 4. 4. The initial experience suggests that the trouble-free patency rate is high. 5. 5. The procedure is indicated when suitable vessels are not available at the wrist or forearm.

Are the native kidneys responsible for erythrocytosis in renal allorecipients

The development of erythrocytosis following renal transplantation has been reported to be caused by a number of factors. These include acute and chronic rejection, hydronephrosis and renal artery stenosis. In this study, seven patients were noted to have erythrocytosis with hematocrits ranging between 53.5 and 66%. Serum erythropoietin levels were elevated and ranged between 11 and 60 mU/ml with a mean of 31.9 mU/ml in six of seven patients. Selective catheterization of veins of native and transplanted kidneys in three patients revealed mean serum levels of 40.9 and 13.0 mU/ml, respectively. This suggests that excess erythropoietin is being produced from the diseased native kidneys. Bilateral nephrectomy in one patient cured erythrocytosis and dropped systemic levels of erythropoietin (EP) to 6.1 mU/ml. In four of the remaining five patients, hematocrits came down spontaneously to within normal over a 1− to 3-year period. Consequently, it appears that in a number of transplant patients the retained diseased kidneys, having lost all excretory and concentrating function, may remain capable of functioning as endocrine erythropoietin-producing organs.

The prognostic value of the eosinophil in acute renal allograft rejection.

A case report of marked peripheral blood eosinophilia and eosinophilic infiltration of a rejected renal allograft in a transplant recipient stimulated our review of the clinical course of 132 consecutive renal transplant recipients. A total of 187 acute rejections occurred in 112 patients. Diagnosis was made by renal biopsy in 124 cases. The percentage of eosinophils in the leukocyte differential of patients with irreversible rejection was 5.2 +/- 5.7 (mean +/- SD) versus that seen in patients with reversible rejection, 2.9 +/- 3.5 (P less than .05). The difference in the total eosinophil counts in each group was not statistically significant. Patients with peripheral blood eosinophil percentages greater than or equal to 4% had a 37.9% irreversible rejection rate, whereas those who had less than 4%, had a 22.4% loss rate (P less than .01). Six of seven patients with greater than or equal to 2% eosinophils in the inflammatory infiltrate of their renal allograft lost their kidney, whereas grafts with less than 2% eosinophils had a 36.8% loss rate (P less than .02). We conclude that the increased presence of eosinophils in the peripheral blood and/or renal allograft biopsy specimen is an adverse prognostic factor for acute rejection outcome.

Effect of cyclosporine on total lymphocyte and T-cell counts in renal-transplant recipients.

Persons who are seropositive for HTLV-III are at risk for the development of T-cell immunosuppression of varying degrees of severity and those who are concurrently infected with Mycobacterium tuberculosis (i.e. those with positive tuberculin skin tests) may therefore also be at high risk for contracting and then transmitting tuberculosis. In the setting of a rapidly spreading AIDS epidemic preventive therapy with isoniazid in persons seropositive for HTLV-III and with a positive tuberculin skin test could be a major public health importance. Such chemoprophylaxis is likely to be effective since tuberculosis responds very well to standard treatment with antibiotics even among patients with AIDS. From January 1980 through October 1985 90 cases of tuberculosis associated with AIDS were documented in Florida. From January 1980 through June 1983 17 of 25 such reported cases (65%) occurred among Haitian immigrants. Since July 1983 28 of 65 such cases (43%) have occurred among Haitians and 29 of 65 (44.5%) have occurred among US natives. In Florida therefore cases of tuberculosis associated with AIDS seem to be increasing both in their total number and in the number and percentage of patients who are US natives. It is likely that the number of cases of tuberculosis related to HTLV-III immunosuppression exceeds that associated with AIDS since tuberculosis tends to precede the syndrome by months of years. Furthermore it is possible that some cases of tuberculosis related to HTLV-III immunosuppression are never followed by severe opportunistic infections or tumors diagnostic of AIDS. These factors at least in part may explain the recent abrupt increase in the incidence of tuberculosis (43%) among persons born in the United States and residing in southeast Florida. Furthermore the incidence of tuberculosis may increase in other areas of the US and in other parts of the world (e.g. developing countries) where tuberculosis infection is prevalent and the rates of HTLV-III infection and AIDS are rising. Tuberculosis is the only AIDS-related infection that is spread to normal persons by the aerosol route and is preventable by chemoprophylaxis. Persons with a confirmed positive HTLV-III serologic test (especially those in high-risk groups for AIDS) should be advised to have a tuberculin skin test. If the skin test is positive or if there has been a documented positive skin test in the past such persons should be offered isoniazid prophylaxis especially if T-cell testing already shows immunosuppression.

Reevaluation of T cell subset monitoring in cyclosporine-treated renal allograft recipients.

The predictive value of peripheral blood T cell subset monitoring in renal allograft recipients has been questionable, and there has been no information concerning the correlation of T cell subset changes with the clinical event related to cyclosporine nephrotoxicity. This study was conducted to investigate the clinical usefulness of serial T cell subset monitoring in 34 consecutive renal transplant patients treated with cyclosporine by determining the total peripheral lymphocyte count and T cell subset counts using Leu-4, Leu-3ab, and Leu-2a monoclonal antibodies and flow cytometry up to 6 months after transplantation. The absolute counts of all cells were lower in transplanted patients than those of normal controls, but were not different from those of hemodialysis patients. During infection, the helper/suppressor (H/S) ratio and the cell counts, except for suppressor cells, decreased significantly. Within one week prior to rejection, all cell counts also decreased significantly. Furthermore, cell counts before steroid-resistant rejection were significantly lower than those before steroid-responsive rejection. In contrast, lymphocyte and T cell counts were increased significantly within one week prior to cyclosporine nephrotoxicity being diagnosed; the H/S ratio was not correlated with rejection or toxicity. These results indicate that H/S ratio is not associated with clinical events of renal allograft recipients, but serial lymphocyte and T cell subset counts can provide valuable information for the differentiation of rejection from cyclosporine nephrotoxicity, and also for predicting the outcome of the allograft rejection.

Polyarteritis Nodosa Involving Only the Main Renal Arteries

A unique case of accelerated hypertension and acute anuria in a 24-year-old man is presented. Clinically, the patient was found to have obstruction of both main renal arteries caused by extensive bilateral thrombosis. Microscopically, a healing panarteritis involving only the main renal arteries was found. This was associated with acute renal infarction and tubular atrophy in the left kidney. This appears to be an unusual variant of polyarteritis nodosa limited to both main renal arteries.

The Kimray-Greenfield vena cava filter: A case of unusual misplacement

An unusual case of misplacement of a Kimray-Greenfield filter in an hepatic vein is described and preventive measures are suggested.

Spermatic cord: Cause of ureteral obstruction in renal allotransplant recipients

Two cases of renal allotransplants are presented with urologic complications caused by the spermatic cord. Management of these patients is discussed, and a question is raised about the insistence of placing the ureter under the spermatic cord in all cases.

Catecholamine responses to orthostatic stimulation in anephric man

Abstract Acute experiments on nephrectomized animals suggest inhibition of adrenergic reflexes in the absence of renal humoral factors. That renal failure patients rendered anephric for control of hypertension also have difficulty with blood pressure regulation is confirmed by the blood pressure instability and hemodialysis shock in anephric patients. In the present study, anephric patients were stimulated by passive orthostatic tilting to the 75°, head-up position. Elevated plasma arterial and venous epinephrine and norepinephrine contents were found at rest and after tilting. The relative increase in circulating catecholamines after tilting is consistent with previous studies in normal patients. The resting elevation of catecholamines in these anephric patients suggests either loss of a renal factor restraining adrenergic activity or a chronic stimulus to sympathetic discharge such as hypovolemia.

Persistent clot anuria complicating renal transplant biopsy.

Serious morbidity from renal transplant biopsy is reported to be infrequent. However, 4 of 43 patients who had renal transplant biopsy between July, 1981, and March, 1984, experienced anuria from upper urinary tract obstruction by blood clots. Although these clots usually dissolve, 3 patients (7%) experienced persistent clot anuria and deterioration of renal function. Awareness of this complication is important. Retrograde pyelography and ureteral catheterization are preferred primarily for diagnosis and treatment. Percutaneous techniques are reserved for those cases in which the ureter cannot be catheterized cystoscopically.