Gerd Rüdiger Hetzel

Iliac artery stenosis proximal to a kidney transplant: Clinical findings, duplex-sonographic criteria, treatment, and outcome

Background. Stenosis of the iliac segment proximal to the transplant renal artery (Prox-TRAS) is an uncommon cause of graft dysfunction and hypertension. We assessed the role of duplex sonography (DS) in regard to clinical and angiographic findings and followed the patients after percutaneous transluminal angioplasty (PTA), PTA stenting (PTAS), or surgery. Methods. From January 1988 to August 2001, 97 of 1,064 kidney recipients underwent angiography for clinical or Doppler-sonographic suspicion of vascular problems. Kidney function, blood pressure, medication, and DS findings after renal transplantation (RTx) at the time of diagnosis of Prox-TRAS and after treatment were evaluated. Results. Prox-TRAS was diagnosed in 16 patients (1.5%) (49.6±6.9 years). Four patients demonstrated early presentation of Prox-TRAS 1 to 7 days after RTx (group A), leading to acute renal failure but without hypertension. In all patients, DS revealed pulsus parvus et tardus, low pulsatility index (PI) (<1.0), and a pathologic flow profile in the iliac artery proximal and distal to the graft. After treatment (surgery in two patients, PTA in one patient, PTAS in one patient), all patients developed good renal function (creatinine 1.7±0.9 mg/dL). PI increased from 0.9±0.1 to 1.2±0.1 (P =0.04), and flow profile within the iliac artery distal to the graft normalized. Late presentation (3–209 months after RTx) of Prox-TRAS was observed in 12 patients (group B), causing an increase of creatinine in 11 patients (two patients receiving dialysis treatments), impairment of blood pressure (141±15 and 80.7±7 to 160±18 and 85±7 mm Hg, P =0.009), and an increase in antihypertensive drugs (2.1±1.1 and 4.3±1, P =0.003) in all patients. The PI was decreased when compared with values early after RTx (1.6±0.4 to 1.2±0.3, P =0.007), and flow profile in the iliac artery was pathologic. All patients except one were managed by surgery (n=6), PTA (n=1), or PTAS (n=4). Creatinine (2.7±1.4 to 1.8±0.4 mg/dL, P =0.02) and blood pressure (160±18/85±7 mm Hg to 138±7/82±9, P =0.018) improved. Antihypertensive drugs were reduced to 2.8±0.8 (P =0.01). PI increased from 1.2±0.3 to 1.9±0.5 (P =0.01). Flow profile within the iliac artery distal to the graft anastomosis normalized. Kidney function, blood pressure, and PI remained unchanged during follow-up (82±69.9 months) in both groups. Conclusions. Prox-TRAS is rare. Because clinical symptoms are similar to those of transplant renal artery stenosis, DS is a valuable tool for diagnosis and follow-up for this type of vascular lesion. Selective treatment with PTA, PTAS, or surgery improves kidney function and hypertension.

Assessment of radiocontrast media induced renal vasoconstriction by color coded duplexsonography

Introduction: Changes in renal hemodynamics are suspected to be one of the major pathogenetic correlates in radiocontrast media-induced nephrotoxicity. We investigated whether color-coded duplex sonography is an appropriate method to document changes in intrarenal vascular resistance, after intravenous injection of the low-osmolar contrast material Iopamidol. Methods: Intrarenal arterial doppler wave forms were analyzed every minute after intravenous injection of 100 mL Iopamidol in 10 patients during a voiding cystourogram-procedure. The Resistive Index (RI) of each flow curve, reflecting intrarenal flow resistance, was calculated and compared to the mean of four RI measurements taken before contrast media application. Results: One minute after injection of Iopamidol the RI remained unchanged compared to the baseline standard of 0.70. In measurements obtained 2, 3, 4, and 5 minutes after Iopamidol injection a statistically significant rise was seen: (minute 2: 0.74, p < 0.001/minute 3: 0.75, p = 0.001/minute 4: 0.72, p = 0.018/minute 5: 0.74, p = 0.031). During the further course, the resistive indices decreased progressively and showed no significant difference in comparison with the baseline standard value. Conclusion: Color coded duplex sonography is a simple method to detect changes in renal flow resistance after application of radiocontrast media. Based on our results, we believe that the analysis of intrarenal arterial doppler flow profiles constitutes an ideal method to investigate pathophysiologic mechanisms of radiocontrast media-induced nephrotoxicity, as well as pharmacological concepts in nephroprotectivity.

HRCT Findings of Amiodarone Pulmonary Toxicity: Clinical and Radiologic Regression

Amiodarone is an antiarrhythmic drug that can cause interstitial pneumonitis leading to pulmonary fibrosis. A 62-year-old man suffering from atrial fibrillation and recurrent dyspnea was treated with amiodarone. After 15 months of treatment, HRCT revealed bilateral interstitial and alveolar opacifications with high-attenuating pleural-parenchymal consolidations, suggesting amiodarone induced pneumonitis. Three months after cessation of amiodarone treatment, HRCT shows complete regression of pneumonitis. Amiodarone pneumonitis can be misinterpreted and mistreated in patients with further underlying diseases. The present case report demonstrates the diagnostic value of HRCT in the diagnosis of interstitial pneumonitis.

Systemische AL-Amyloidose: Klinischer Verlauf und Grenzen der Melphalan-Therapie

Zusammenfassung□ HintergrundDie Prognose der systemischen AL-Amyloidose ist trotz gesicherter Effekte einer Chemotherapie mit Melphalan und Prednison ungünstig, eine Remission klinischer Symptome kann nicht in allen Fällen erwartet werden. Der Verlauf der Erkrankung und das Ansprechen auf die Therapie wird möglicherweise durch Ausmaß und Verteilung der Organmanifestationen bei Diagnosestellung beeinflußt. Wir beschreiben eine Patientengruppe mit im Vordergrund stehender Nierenbeteiligung und berichten über die Behandlungsergebnisse.□ Patienten15 Patienten mit histologisch gesicherter AL-Amyloidose ohne symptomatisches Myelom (vier Frauen, elf Männer, mittleres Alter 61 [34 bis 71] Jahre) wurden in unserer Klinik behandelt und im Verlauf der Erkrankung betreut.□ ErgebnisseBei häufig unspezifischen Erstsymptomen betrug die Dauer bis zur Diagnosestellung maximal 28 Monate. Die Nierenbeteiligung bestimmte meist die klinische Symptomatik, zum Zeitpunkt der histologischen Sicherung der Amyloidose war bei allen Patienten eine Proteinurie oder eine Niereninsuffizienz nachzuweisen. Zehn Patienten wurden mit einem Melphalan und Prednison enthaltenden Chemotherapieschema behandelt; in keinem Fall konnten wir eine deutliche Besserung der klinischen Symptomatik beobachten. Ein Patient im weit fortgeschrittenen Stadium der Erkrankung verstarb nach Durchführung einer Hochdosis-Melphalan-Therapie mit autologer Stammzelltransplantation infolge einer Sepsis.□ SchlußfolgerungEine absolute Indikation zur Chemotherapie sehen wir nicht. Die ungünstige Gesamtprognose — 14 Patienten verstarben im Mittel 13 Monate nach Diagnosestellung — erfordert ein besonders sorgfältiges Abwägen von potentiellem Nutzen und möglichen Risiken der zytostatischen Therapie.Abstract□ BackgroundDespite significant effects of melphalan and prednisone in the therapy of systemic AL-amyloidosis, overall prognosis is poor and remission of clinical symptoms cannot generally be expected. The course of the disease and results of therapy are possibly influenced by the degree and distribution of organ manifestation at the time of diagnosis. We report a group of patients with renal involvement as the main manifestation of disease.□ PatientsFifteen patients with systemic Al-amyloidosis without symptomatic myeloma (4 women, 11 men, median age 61 [34 to 71] years) have been attended to at our department and were treated throughout the course of the disease.□ ResultsSince primary symptoms were frequently unspecific, the maximum time to diagnosis came to 28 months. Renal involvement was primarily evident at the time of diagnosis when all patients manifested proteinuria or renal insufficiency. Ten patients were treated with a melphalan and prednisone containing chemotherapeutic protocol. A significant clinical improvement was observed in no case. One patient in an advanced stage of disease died after the administration of a high-dose regimen of melphalan with blood stem-cell support subsequent to sepsis.□ ConclusionWe do not see an absolute indication for chemotherapy. The unfavorable prognosis — 14 patients died an average of 13 months after diagnosis — requires a particularly careful consideration of potential benefits and possible risks accompanying cytostatic therapy.BACKGROUND Despite significant effects of melphalan and prednisone in the therapy of systemic AL-amyloidosis, overall prognosis is poor and remission of clinical symptoms cannot generally be expected. The course of the disease and results of therapy are possibly influenced by the degree and distribution of organ manifestation at the time of diagnosis. We report a group of patients with renal involvement as the main manifestation of disease. PATIENTS Fifteen patients with systemic Al-amyloidosis without symptomatic myeloma (4 women, 11 men, median age 61 [34 to 71] years) have been attended to at our department and were treated throughout the course of the disease. RESULTS Since primary symptoms were frequently unspecific, the maximum time to diagnosis came to 28 months. Renal involvement was primarily evident at the time of diagnosis when all patients manifested proteinuria or renal insufficiency. Ten patients were treated with a melphalan and prednisone containing chemotherapeutic protocol. A significant clinical improvement was observed in no case. One patient in an advanced stage of disease died after the administration of a high-dose regimen of melphalan with blood stem-cell support subsequent to sepsis. CONCLUSION We do not see an absolute indication for chemotherapy. The unfavorable prognosis--14 patients died an average of 13 months after diagnosis--requires a particularly careful consideration of potential benefits and possible risks accompanying cytostatic therapy.