Margaret G. Zelch

Post-transplant renal artery stenosis : Impact of therapy on long-term kidney function and blood pressure control

PURPOSE We assessed the long-term outcome of different treatment methods for transplant renal artery stenosis. MATERIALS AND METHODS Outcome data for 23 patients with transplant renal artery stenosis treated during a 16-year period were reviewed and analyzed. RESULTS There was a higher incidence of renal artery stenosis in cadaveric donor kidneys compared to living donor kidneys (2% versus 0.3%, p < 0.02), and in cadaveric kidneys from pediatric donors less than 5 years old compared to those from adults (13.2% versus 1.3%, p < 0.01). Six patients underwent primary medical treatment for renal artery stenosis, with a successful outcome in 4 (mean followup plus or minus standard error 57 +/- 22 months) and failure in 2. Of the patients 16 were treated with percutaneous transluminal angioplasty, including 12 who were cured or improved with respect to hypertension (followup 44.7 +/- 7.6 months). Five patients underwent surgical revascularization for renal artery stenosis with postoperative improvement of hypertension (followup 18.8 +/- 11.6 months). Overall, 21 of 23 patients (91%) were treated successfully for transplant renal artery stenosis with cure or improvement of associated hypertension. Posttreatment renal function was stable or improved in 18 patients, while renal function deteriorated due to parenchymal disease in 3. CONCLUSIONS Most patients with transplant renal artery stenosis can be treated successfully. Percutaneous transluminal angioplasty is the initial interventive treatment of choice for high grade renal artery stenosis. Surgical revascularization is indicated if percutaneous transluminal angioplasty cannot be done or is unsuccessful.

Long-term efficacy of ureteral dilation for transplant ureteral stenosis

Transluminal ureteral dilation was performed in 11 renal allograft recipients with transplant ureteral obstruction. Success was achieved in 5 patients (45 per cent) with a followup of 12 to 29 months (mean 19.6 months). All failures have been evident within 12 months of dilation. We conclude that ureteral dilation can provide long-term success in renal allograft recipients. However, continued close long-term monitoring of the anatomical and functional result is mandatory for patients treated in this manner.

Local thrombolysis in the treatment of thrombosed arteries, bypass grafts, and arteriovenous fistulas

We reviewed the results, systemic effects, and complications associated with the selective infusion of low-dose streptokinase in 151 patients. Successful thrombus lysis was achieved in 78% of atherosclerotic thrombotic occlusions less than 30 days old, in 81% of post-procedural occlusions less than 14 days old, and in 87% of patients with thrombosed arteriovenous fistulas no more than 4 days old. During the first 12 hours of treatment 81% to 84% of patients had greater than 50% decrease in plasma fibrinogen levels and 100% showed the same decline after 24 hours of treatment. The thrombin time was prolonged to at least 1 1/2 times the control thrombin time in 33% to 42% of patients measured at 4 hours of therapy and in 93% to 97% of patients measured at 24 hours of treatment. Fifteen patients (9.9%) had major complications. Eleven of these had hemorrhagic complications, two had significant distal emboli, one had a thrombosed brachial artery, and one had a false aneurysm at the catheter entry site. We have found that selective low-dose streptokinase is effective in the treatment of acute and chronic thrombotic occlusions and is a useful adjuvant to vascular reconstruction or percutaneous transluminal angioplasty. Although the local infusion dose is substantially lower than the usual systemic dose, a systemic lytic effect was seen in all patients. Hemorrhagic complications occurred despite customary precautions.

Peripheral artery and bypass graft thrombolysis with recombinant human tissue-type plasminogen activator

Recombinant tissue-type plasminogen activator (t-PA) is a DNA-synthesized thrombolytic agent recently approved for clinical trials. We present the results of t-PA infusions in 18 patients with thrombosed peripheral arteries (12 patients) and peripheral bypass grafts (six patients). The duration of occlusion ranged from 1 to 21 days (mean, 6.8 days). Infusions of t-PA were done by way of an intra-arterial approach at a dose of 0.1 mg/kg/hr. All patients demonstrated thrombus lysis angiographically. Fifteen of 18 (83%) had clinical as well as angiographic improvement. Secondary procedures to maintain patency of the arterial segment were required in seven patients. No complications occurred that were related to the t-PA infusion. No significant prolongation of the prothrombin, thrombin, or activated partial thromboplastin times occurred. At the end of t-PA infusion, the mean circulating fibrinogen level was 59% of the starting value. The therapeutic use of t-PA is still in its preliminary stages and the efficacy and safety of this promising agent need to be further established. From our early experience with t-PA, it appears to be safe as well as effective.

Experience with Percutaneous Transluminal Angioplasty for Renal Artery Stenosis at The Cleveland Clinic

From April 1979 to June 1985 percutaneous transluminal angioplasty was attempted in 68 patients at our clinic to treat renovascular hypertension and/or to preserve renal function. The etiology of renal artery disease was atherosclerosis in 55 patients, fibrous dysplasia in 6, renal transplant arterial stenosis in 5 and postoperative saphenous vein graft stenosis in 2. A successful clinical outcome, defined as a decrease in blood pressure and/or improvement in renal function, was achieved in 12 patients (26.1 per cent) with atherosclerotic renal artery disease, 3 (75 per cent) with fibrous dysplasia, 2 (100 per cent) with saphenous vein graft stenosis and all 5 with transplant renal arterial stenosis (100 per cent). Improved results were observed in patients with nonostial atherosclerotic lesions compared to ostial lesions. There were 23 complications (33.8 per cent) after percutaneous transluminal angioplasty and all but 1 occurred with atherosclerosis. Of these complications 13 (19 per cent) were considered major. Since the beginning of 1983, however, only 3 complications occurred among 32 procedures (9.4 per cent) and only 1 of these was of major significance. When technically feasible, percutaneous transluminal angioplasty can provide effective treatment for selected patients with renal artery stenosis.

Percutaneous Management of Transplant Ureteral Fistulas: Patient Selection and Long-Term Results

Of 24 renal allograft recipients with urinary extravasation 14 (58%) with ureteral fistulas were selected for percutaneous management in an attempt to obviate secondary operative intervention. The initial procedure in all cases was placement of a percutaneous nephrostomy tube with subsequent internal or internal/external stenting. With a mean followup of 47 months, the percutaneous management proved definitive in 5 patients (36%) and palliative in 1 (7%). The other 8 patients (57%) subsequently required open operative intervention. With this study, we conclude that percutaneous techniques can provide long-term definitive management for at least some transplant ureteral fistulas. However, even in a highly selected group of patients success rates will be limited.

Percutaneous extraction of renal calculi in patients with solitary kidneys

Percutaneous techniques have become widely accepted for the management of many patients with renal calculi. Little is known, however, about the efficacy of utilizing these procedures for patients with solitary kidneys. We studied five such patients to determine whether percutaneous techniques could be utilized safely, effectively, and efficiently in this setting. The results achieved suggest that the percutaneous removal of renal calculi should be considered a viable treatment option for selected patients with stones in solitary kidneys.

Right Renal Mass with Vena Caval Thrombus

This case illustrates the difficulties that sometimes occur in the evaluation of patients with a nonfunctioning kidney. Because of the clinical presentation, suggestive of renal cell carcinoma, no urinary cytology study was obtained from the affected kidney. This study certainly would have led to the correct diagnosis. Despite this fact, the operative management would not have changed except for complete removal of the ureter. In our case we elected to follow the distal ureter by ureteral washings and ureteroscopy during follow-up cystoscopy studies to preclude a further operation. Although no data are available on the role of adjuvant therapy in these patients, because of the poor prognosis associated with such extensive disease we gave our patient 2 courses of M-VAC in an attempt to prevent progression of the disease.

Use of an Intercostal Vein for Central Venous Access in Home Parenteral Nutrition: A Case Report

A key factor in the success of a home parenteral nutrition program is prolonged and safe access to the central venous system. There are some patients, however, in whom the cephalic, external jugular, internal jugular, subclavian, and saphenous veins cannot be used. In these patients, cannulation of an intercostal vein can be useful for central venous access. Such a patient was recently presented to our medical care facility with bilateral subclavian vein thrombosis, left external iliac vein thrombosis, and superior vena cava obstruction above the level of the azygous vein. A Broviac catheter was successfully introduced via a right intercostal vein cutdown with the catheter tip lying in the azygous arch. This is the first known description in an adult patient in the use of an intercostal vein to gain access into the central venous system.

Role of percutaneous nephrostomy inpatients with upper urinary tract transitional cell carcinoma

Percutaneous nephrostomy has become a well-established procedure for a wide variety of urologic disorders. However, its role in the management of patients with upper urinary tract transitional cell carcinoma has not been defined. We utilized percutaneous nephrostomy in 23 renal units for the evaluation or treatment of 21 patients in whom standard techniques were inconclusive or inadequate. The percutaneous nephrostomy provided adequate relief of obstruction in the face of significant azotemia or infection. Diagnostic abilities were improved through the use of antegrade pyelography, selective cytologic examination, and, at times, by providing direct access for endoscopic visualization and biopsy. In select cases, the percutaneous access provided a route for definitive or adjunctive treatment of the lesion. Complications were few and seeding of the tract or local tumor spread has not occurred at follow-up ranging from one to one hundred twenty-one (mean 27.8) months.