Hans Løkkegaard

Influence of Normal Central Venous Pressure on Onset of Function in Renal Allografts

The central venous pressure was kept above 5 cmH2O during the perioperative and early postoperative period as guidance for fluid replacement in 31 patients receiving a renal graft (group B). In 30 other transplant recipients the central venous pressure was not measured (group A). The two groups were otherwise comparable. Onset of graft function within the first 3 postoperative days was significantly more frequent in group B than in group A (62% vs. 30%), despite absence of difference in the measurable warm and cold ischemic periods. Fluid replacement guided by the central venous pressure thus is concluded to reduce the number of kidneys with delayed function in the immediate postoperative period.

Perioperative Doppler Ultrasonography: Renal Detection of Renal Graft Perfusion

Irreversible damage of renal transplants may be prevented if insufficient graft perfusion can be detected perioperatively. Colour and spectral Doppler ultrasonography were performed in 30 consecutive renal transplants. The perfusion of the graft and the Resistive Index (RI) were evaluated perioperatively (perioperatively and less than 15 min postoperatively) and 24 h after the operation in all patients. In four cases (13.3%) RI > 0.9 was detected and immediate surgical correction of the cause led to a normalization (RI < 0.8) in all four cases. A RI < 0.9 required no intervention in 26 cases (86.7%). All renal grafts in this series were functioning 1 month postoperatively. In a comparative group, 30 consecutive transplants carried out at our institution without perioperative Doppler ultrasonography evaluation, a loss of four renal grafts perioperatively was recorded retrospectively. We conclude that perioperative ultrasonography Doppler evaluation may provide an easy applicable and reliable method for early detection of insufficient renal graft perfusion, allowing surgical correction before irreversible damage of the graft occurs. RI > 0.9 is pathological. A continuation of the study is required to clarify the long-term value of perioperative Doppler ultrasonography graft monitoring.

The relative prognosis of nodular and diffuse diabetic nephropathy.

Material and methods: One hundred and forty-four diabetic patients with biopsy-proven diffuse diabetic glomerulosclerosis (DIF), 134 patients with nodular diabetic nephropathy (NOD) and 152 diabetic patients with nondiabetic-related morphology (104 chronic nephropathy, 48 primary GN) were followed for up to 12 years to determine the clinical prognosis. Results: Comparing the NOD patients with the DIF patients, there were more females (41% vs 26%, p < 0.05) and they were more often uremic at biopsy (24% vs 12%, p < 0.01), but the age was similar (53.3 years vs 50.1 years, NS). There was no difference in diabetes type I and II incidence. Compared with the general population, the odds ratio (OR) for death was 7.2 (confidence interval 5.5-9.5) for DIF and 10.8 (8.5-13.7) for NOD. The OR for combined renal or patient death was: DIF 15.2 (11.7-19,7); NOD 24.6 (19.4-31.0). After correction for age, sex, and pre-existing uremia, NOD had a 1.70 (p < 0.01) times increased risk of death compared with DIF, and a 2.42 (p < 0.01) times increased risk of renal failure. The life expectancy for NOD was 4.0 years, and average time to dialysis was 2.1 years. NOD prognosis was similar to other chronic nephropathy. The incidence of all atherosclerotic complications except AMI was twice as high in NOD than DIF. Diabetes type had no influence on prognosis. The estimated incidence of diabetic nephropathy was 56/mio/year. Conclusion: Nodular diabetic nephropathy has a poorer prognosis than diffuse due to a higher rate of atherosclerotic and uremic complications.MATERIAL AND METHODS One hundred and forty-four diabetic patients with biopsy-proven diffuse diabetic glomerulosclerosis (DIF), 134 patients with nodular diabetic nephropathy (NOD) and 152 diabetic patients with nondiabetic-related morphology (104 chronic nephropathy, 48 primary GN) were followed for up to 12 years to determine the clinical prognosis. RESULTS Comparing the NOD patients with the DIF patients, there were more females (41% vs 26%, p < 0.05) and they were more often uremic at biopsy (24% vs 12%, p < 0.01), but the age was similar (53.3 years vs 50.1 years, NS). There was no difference in diabetes type I and II incidence. Compared with the general population, the odds ratio (OR) for death was 7.2 (confidence interval 5.5-9.5) for DIF and 10.8 (8.5-13.7) for NOD. The OR for combined renal or patient death was: DIF 15.2 (11.7-19.7); NOD 24.6 (19.4-31.0). After correction for age, sex, and pre-existing uremia, NOD had a 1.70 (p < 0.01) times increased risk of death compared with DIF, and a 2.42 (p < 0.01) times increased risk of renal failure. The life expectancy for NOD was 4.0 years, and average time to dialysis was 2.1 years. NOD prognosis was similar to other chronic nephropathy. The incidence of all atherosclerotic complications except AMI was twice as high in NOD than DIF. Diabetes type had no influence on prognosis. The estimated incidence of diabetic nephropathy was 56/mio/year. CONCLUSION Nodular diabetic nephropathy has a poorer prognosis than diffuse due to a higher rate of atherosclerotic and uremic complications.

Renography and biopsy-verified acute rejection in renal allotransplanted patients receiving cyclosporin A

Acute impairment of renal function caused by cyclosporin A can be hard to differentiate from acute rejection. Therefore, kidney function after cadaveric allograft transplantation was repeatedly determined by renography in 42 patients receiving either high dose cyclosporin A (32 patients) or azathioprine and prednisone (10 patients) until a graft biopsy showed either acute rejection or no rejection within the first 5 postoperative weeks. The graft function as judged from the renograms was significantly poorer when cyclosporin A was used than when azathioprine and prednisone were the immunosuppressants. In the azathioprine and prednisone group a biopsy showing acute rejection was always preceded by a deterioration in the renogram. In cyclosporin A treated patients a graft biopsy following an early deterioration in the renogram showed acute rejection in only 56% of the biopsies. It was not possible to identify a time course or a function level of the renogram that could predict rejection in these patients. It is concluded that graft biopsies should be used liberally to diagnose rejection during cyclosporin A treatment if surgical complications after transplantation have been ruled out. Radionuclide studies may offer an invaluable aid in determining a nonnephrotoxic initial dose of the drug.

Paramedian Versus Midline Incision for the Insertion of Permanent Peritoneal Dialysis Catheters

A randomized trial was conducted to examine the influence of the site of catheter insertion on the mechanical complications associated with the use of peritoneal dialysis catheters (pericatheter leakage/herniation and tip migration). 37 patients requiring a dialysis catheter for future CAPD were randomized to insertion by either a midline (prior standard approach) or a lateral incision (new approach). Thirteen catheters (6 midline, 7 lateral) failed for mechanical reasons--mainly irreversible tip migration. The one year estimated catheter survival without mechanical failure was found to be similar in the two groups: midline (59%) and lateral (51%), (0.4 less than p less than 0.5).

Evaluation of kidney grafts with 99mTc-methylene diphosphonate within 36 hours after transplantation: A marker of ischemic damage

In order to evaluate renal ischemic damage in transplanted kidneys, renal scintigraphy with 99mTc-methylene disphosphonate was performed in 30 kidney grafts within 36 h after transplantation. The renal uptake was monitored for 100 s at 10-min intervals during 90 min following injection. Seventeen patients had an average uptake of radioactivity in the kidney on the 60-, 70-, 80-, and 90-min scintigrams expressed as a percentage of the activity present on the 10-min scintigram of 150% or less (low) and 13 patients had an average uptake of radioactivity of above 150% (high). There was no relationship between the average uptake of radioactivity and warm and cold ischemia times (or the combined value: corrected ischemia), maximal function, reversible rejection, and ureteral obstruction. A significant correlation was found between the average uptake of radioactivity in the kidney and onset of function. Seventy-six per cent of the grafts with a low average uptake of radioactivity had an onset of function on or before day 10 after operation (early) whereas only 15% of the kidneys with a high average uptake of radioactivity had an early onset of function. Twelve per cent of the patients with a low average uptake of radioactivity in the kidneys had their grafts removed for various reasons within 2 months after transplantation, whereas 54% with a high average uptake of radioactivity had their grafts removed. It is concluded that 99mTc-methylene diphosphonate scintigraphy may be useful in the prognostic assessment of graft onset of function and of graft survival.

Cold Hypersensitivity and Finger Systolic Blood Pressure in Hemodialysis Patients

In patients on maintenance hemodialysis the blood pressure in the fingers of the arm with arteriovenous fistula was significantly lower than in the fingers of the other arm. This is explained by the increased arterial blood flow to the arm with the fistula, giving physiological pressure reduction. Six of ten uremic patients on maintenance hemodialysis complained of Raynauds phenomenon. This was confirmed by a cold provocation test, which showed significant improvement after hemodialysis. The mechanism of Raynauds phenomenon in these patients is assumed to be functional, but no clear explanation has been found.

90-minute 99mTc-MDP scintigraphy and 131I-hippuran renography in recently allotransplanted kidneys: Evaluation of renal ischemia

Renal ischemic damage in 31 transplanted kidneys was evaluated by renal scintigraphy with 99mTc-methylene diphosphonate and 131I-hippuran renography. The renal uptake of phosphate was monitored for 100 s at 10-min intervals during 90 min following injection. The average uptake of radioactivity in the graft on the 60-, 70-, 80-, and 90-min scintigram was calculated. Grafts with an average uptake of 99mTc-MDP of 150% or below had a significantly more frequent onset of function within the first 3 days following operation than grafts with an average uptake above 150%. Renography was shown to be an equally good method for predicting the onset of function. The success rate (correct prediction of onset of function) was almost equal for the two methods, but in 11 patients the results of the two methods diverged. An obvious degree of overlap limits the usefulness of both methods in any one particular patient. It is concluded that renal scans with 99mTc-MDP and 131I-hippuran renography are complementary in the assessment of ischemic damage following transplantation.

Risk factors in haemodialysis patients : Evaluation of commonly measured variables on death rate

This study evaluates risk factors among commonly measured laboratory values and clinical findings in haemodialysis patients, followed by attempts to identify optimal treatment strategies. Average plasma concentrations of albumin, protein, CO2, urea and creatinine, and average values of systolic and diastolic blood pressure, together with information on gender, age and renal diagnosis, were related to survival rate in 210 sequences of haemodialysis treatment during a period of 94 months. The average treatment time was 12.6 months (range 1-94). The material was analysed with stepwise regression analysis using the Cox proportional hazard model (BMDP 2L), and actuarial life table analysis was performed to illustrate the magnitude of influence of the independent variables on patient survival (BMDP IL). Patient survival was negatively correlated with age and positively correlated with average plasma concentrations of albumin. Surprisingly, patient survival was negatively correlated with plasma CO2. Patient survival was significantly lower in diabetics.

Angiography in Non-Functioning Renal Allografts Receiving Cyclosporin A

During a two-year period angiography was performed in 10 out of 40 initially perfused kidney allografts within the first 3 postoperative weeks. Immunosuppression was in all cases performed with cyclosporin A. The indication for angiography was mainly deterioration in the graft function as judged from the renograms or inadequate demonstration of the graft during intravenous radionuclide angiography. At angiography, neither arterial nor venous occlusion was found, and it was normal in 5 patients. It is concluded that during cyclosporin A treatment angiography cannot be recommended on the above mentioned indications in the early postoperative period. A graft biopsy seems sufficient.