Michael J. Lemmers

Mast cell involvement in interstitial cystitis

A prospective study was designed to examine the relationship of mast cells, and eosinophilic leukocyte density and mediator levels to clinical and histological parameters of interstitial cystitis. Interstitial cystitis and control patients underwent bladder biopsy with histological examination, and quantification of intact and degranulated mast cell and eosinophilic leukocyte density. In addition, bladder tissue histamine content, urinary prostaglandin E2 excretion rates, and serum and urinary major basic protein levels were determined. A strong relationship among detrusor mast cell density, especially degranulated, and degree of epithelial loss, submucosal inflammation, epithelial ulceration, urinary pyuria and response to treatment was noted. Bladder tissue histamine content and urinary prostaglandin E2 excretion were increased in the interstitial cystitis patients. Eosinophil density in bladder biopsies was low uniformly, and interstitial cystitis and control patients showed no statistical difference. In addition, serum and urinary major basic protein levels were below the accepted normal lower limits for this protein. Therefore, our study demonstrates a relationship between the mast cell and the inflammatory process of interstitial cystitis. No similar relationship was noted for the eosinophil.

Major Role for Arterial Disease in Morbidity and Mortality After Kidney Transplantation in Diabetic Recipients

Objective To identify clinical characteristics of diabetic end-stage renal disease patients that place individual transplant candidates at high risk for arterial morbidity and mortality after transplantation. Research Design and Methods We studied the course of 101 sequential renal allograft recipients with insulin-dependent diabetes mellitus, transplanted between 10 November 1980 and 1 April 1986. Arterial disorders were tabulated from medical records and interviews with individual patients, their families, and their private physicians. Documentation of discrete arterial events included recorded physical examinations, radiographic studies, laboratory data, electrocardiograms, peripheral vascular flow studies, and operative reports. The prevalence of preoperative arterial disease was compared with the occurrence of new arterial events after kidney transplantation. Results Within a mean follow-up period of 47 mo, a 30% absolute mortality rate was observed. Of these deaths, 57% resulted from arterial disorders. Clinical manifestations of arterial disease were recognized in 41% of recipients before transplantation, and 78% of these patients suffered new vascular events after transplantation. Of the entire sample, 57% developed at least one new complication of arterial disease after transplantation, whereas only 34% had no vascular diagnosis before or after transplantation. Cerebral, coronary, and peripheral arterial complications after transplantation occurred in 14, 28, and 36% of the patients, respectively. The corresponding incidences of stroke, myocardial infarction, and amputation were 12, 14, and 25%. Pretransplant coronary artery disease predisposed to new coronary eventsafter transplantation, but only peripheral arterial complications occurred more often after transplantation compared with the preoperative period. The probability of arterial complications or death correlated with patient age at first transplant and duration of diabetes but not with sex or smoking history. Conclusions Intrinsic arterial disease in diabetic renal allograft recipients contributes heavily to the long-term morbidity and mortality after transplantation and poses the major threat to survival. Diabetic transplant candidates >35 yr of age or with clincial evidence of arterial disease should undergo an extensive vascular assessment, including stress thallium myocardial imaging and/or coronary arteriography. Such recipients should receive careful preoperative counseling about their excess risk for subsequent arterial disorders.

Efficacy and safety of low molecular weight heparin in renal transplantation

BACKGROUND Deep venous thrombosis (DVT) is a common problem with potentially devastating results in patients undergoing major surgical procedures. Certain renal transplant recipients are particularly at risk for allograft loss as a consequence of renal vein and artery thrombosis. Over the past few years, low molecular weight heparin has been well established as an accepted modality of treatment and prophylaxis of DVT. The efficacy and safety of low molecular weight heparin in the prophylaxis of DVT following renal transplantation in adults has not previously been reported. METHODS Dalteparin was administered to 120 adult renal transplant recipients postoperatively at the Oregon Health Sciences University. RESULTS No patient developed allograft arterial or venous thrombosis. One patient developed subclavian vein thrombosis. No bleeding complications were encountered, and side effects were very minimal. CONCLUSION Prophylaxis with dalteparin is an effective and safe modality for the prevention of thrombosis in adult patients undergoing renal transplantation.

Renal Adenocarcinoma with Solitary Metastasis to the Contralateral Adrenal Gland: Report of 2 Cases and Review of the Literature

We report 2 rare cases of renal adenocarcinoma with solitary metastasis to the contralateral adrenal gland, 1 recognized synchronously with the primary neoplasm and 1 found 15 years after nephrectomy. The latter case represents the longest reported interval between nephrectomy and treatment of a solitary contralateral adrenal metastasis of renal adenocarcinoma. Distinction of these metastatic tumors from primary adrenocortical carcinoma was facilitated by immunohistochemical markers. Twelve other reported cases of renal adenocarcinoma with solitary contralateral adrenal metastasis support aggressive surgical management of this lesion.

Scrotal Arteriovenous Malformation: Case Report and Literature Review

We report a rare case of scrotal arteriovenous malformation in an adolescent. Arteriovenous malformation of the scrotum is distinguished radiographically and histologically by numerous arterioles and thick walled veins with no intervening capillary bed. The cardinal sign is a bruit. Complete excision is recommended as definitive treatment. Preoperative angio-embolization may be helpful but it should not be relied upon for clinical resolution.

De novo carcinoma of the lower urinary tract in renal allograft recipients.

Immunocompetence has been postulated as an important defense against the progression of urothelial carcinoma. Three cases of de novo lower urinary tract carcinoma in renal transplant recipients demonstrated the potential for unusually rapid urothelial extension and invasion in chronically immunosuppressed patients. Two patients had a history of perineal condyloma acuminata; tumors from 1 of these harbored the genetic sequences of human papillomavirus type 6. One patient had multiple manifestations of cyclophosphamide-related urothelial injury, including bladder carcinoma. Treatment of 2 patients culminated in a radical operation during which the remaining native urinary system was resected completely, with sacrifice of the allograft kidney in 1 and diversion into an ileal conduit in 1. The remaining patient underwent urethrectomy and partial cystectomy with a sigmoid conduit.

INDICATION, SURGICAL TECHNIQUE AND OUTCOME OF ORTHOTOPIC RENAL TRANSPLANTATION

PURPOSE We review the indication, surgical technique and outcome of orthotopic renal transplantation. MATERIALS AND METHODS The medical records of 1,000 patients who underwent renal transplantation at our institution between August 24, 1993 and August 1, 2000, as well as orthotopic renal transplantation were reviewed. RESULTS Orthotopic renal transplantation was performed in 4 males and 1 female with severe iliac atherosclerosis or retained bilateral iliac fossa kidney transplant. Mean patient age was 56 years. There were 2 patients who received kidneys from living related donors, and 3 underwent cadaveric renal transplantation. Left orthotopic renal transplantation was successful in 4 cases, and 1 was converted to iliac fossa renal transplant because of a pulseless splenic artery and renal artery thrombosis after native renal endarterectomy. Orthotopic renal revascularization was done with splenic artery in 2, native renal artery in 2 and left renal vein in all 4 patients. Urinary tract reconstruction was performed with stented (2) or nonstented (2) ureteroureterostomy. Antibody induction, purine antagonists, calcineurin inhibitors and glucocorticoids were used for immunosuppression. Mean preoperative and 1-month postoperative serum creatinine was 7.9 and 1.3 mg./dl., respectively. Patient and graft survival was 100% during followup, which ranged from 6 months to 5 years. CONCLUSIONS Despite the technical challenges, orthotopic renal transplantation in patients with unsuitable pelvic vessels can result in excellent patient and graft survival.

Cadaver kidney transplantation in patients more than 65 years old

SummaryElderly patients with end-stage renal disease often remain on dialytic therapy because they are at increased risk for mortality and morbidity. We placed 24 cadaver kidney transplants into 24 patients aged 65–74 years between September 1, 1985, and August 31, 1995. Rates of patient and graft survival were compared with those of 404 concurrent first cadaver-kidney transplant recipients between the ages of 20 and 44 years. The 5-year rates of patient and graft survival were not significantly different (86% versus 92% and 77% versus 63%, respectively; study group presented first). Primary cadaver kidney transplantation can be successfully performed in patients older than 65 years when a selection algorithm is applied to exclude active infection, active malignancy, unsuitable anatomy for technical success, high probability of operative mortality, and noncompliance. Pelvic arteriosclerosis and lower urinary tract abnormalities can cause intraoperative technical problems.

Patch and Flap Techniques to Repair Right Renal Vein Defects Caused by Cadaver Liver Retrieval for Transplantation

We describe 2 techniques that allow right renal vein extension and prevent renal vein stenosis if the cephalic portion of the renal vein has been amputated when the liver is separated from the kidneys during multiple organ retrieval. These techniques were successfully used in 8 cadaver kidney transplant recipients.

Extravesical Ureteroneocystostomy for Duplicated Allograft Ureters

We report a modification of unstented, parallel incision, extravesical ureteroneocystostomy for duplicated ureters. The technique is simple and effective, and requires no routine stenting.