Peter P. Frohnert

Long-term follow-up study of periarteritis nodosa

Abstract The records of 130 patients with histologically proved periarteritis nodosa seen at the Mayo Clinic from 1946 through 1962 were reviewed. Intensive corticosteroid or ACTH therapy had been given to 110 of these patients. The expected survivorship, calculated by the life-table method, revealed a five year survival of 48 per cent for the treated patients and 13 per cent for the untreated ones. The presence of hypertension or renal disease at the initial examination seemed to worsen the prognosis. Both disorders were less frequent in patients who had received steroid therapy early in the course of their disease. Subdivision, on clinical grounds, into those with and without pulmonary involvement appeared to have no value in regard to the prognosis. Early and vigorous steroid therapy was of significant value in improving the results in patients with periarteritis nodosa. The majority of patients had to continue this treatment on a long-term basis to suppress symptoms or to prevent exacerbations. Side effects were infrequent.

The Risks of Unilateral Nephrectomy: Status of Kidney Donors 10 to 20 Years Postoperatively

We received requested follow-up information from 105 (73%) of our 144 kidney donors who had undergone unilateral nephrectomy 10 to 20 years previously. Five donors had died of unrelated causes 6 or more years postoperatively. Studies in the remaining 100 donors showed that the current mean serum creatinine concentration was 1.2 mg/dl and the mean 24-hour urinary protein value was 89 mg. Hypertension (defined as 160 mm Hg or more systolic, 95 mm Hg or more diastolic, or both) was present in 19% of the donors. In a subgroup of 66 donors who had had serial serum creatinine determinations, the renal function, as estimated on the basis of these serum creatinine values, had not deteriorated with time. Thus, we consider unilateral nephrectomy in this group of patients relatively safe. Subsequent evaluation will be necessary to ascertain whether these findings prevail.

Graded Exercise Testing and Training After Renal Transplantation: A Preliminary Study

Aerobic exercise training has been used as part of the treatment for a variety of chronic disorders, most notably cardiovascular disease. In order to determine the feasibility and utility of regular exercise after renal transplantation, the responses of 10 patients to graded exercise testing were compared before training (T1), immediately after a program of supervised exercise training (T2), and a mean of 2.2 years after completion of the supervised program (T3). Supervised exercise sessions began a mean of 17 days postoperatively and continued for a mean of 5.5 weeks. Patients were encouraged to continue regular unsupervised exercise thereafter. All patients easily tolerated the supervised exercise sessions, which consisted of treadmill walking and cycle ergometry. Exercise capacity improved 90% between T1 and T2 and an additional 12% between T2 and T3. On the average, patients achieved a normal exercise capacity by 8 weeks after transplantation. Of the 10 patients, 7 had continued regular exercise training at T3. The observed increase in aerobic exercise capacity was probably related to improved renal function, an increased hemoglobin concentration, and the surgical healing process as well as the exercise training. We conclude that supervised exercise training for selected patients after renal transplantation is feasible and worthwhile.

Meclofenamate treatment of recurrent idiopathic nephrotic syndrome with focal segmental glomerulosclerosis after renal transplantation.

Recurrent corticosteroid-resistant nephrotic syndrome with focal segmental glomerulosclerosis (FSGS) caused the failure of a first renal allograft in a 41-year-old man. Recurrence of the nephrotic syndrome in the second renal allograft was successfully controlled by the administration of meclofenamate, and the renal function has remained stable for 2 1/2 years. No accepted treatment is available for corticosteroid-resistant nephrotic syndrome with FSGS. This report suggests that administration of meclofenamate might be beneficial in some patients with corticosteroid-resistant nephrotic syndrome and FSGS. Because of the potential side effects, however, careful supervision of this therapy is of the utmost importance.

Pancreas transplantation at Mayo: III. Multidisciplinary management.

Although pancreas transplantation is a complicated procedure, a good level of success has been achieved because of the introduction of cyclosporine for immunosuppression, improved methods for diagnosing rejection, and a multidisciplinary approach to management. Our immunosuppressive regimen was quadruple therapy with induction by using Minnesota antilymphoblastic globulin. A biopsy technique was instituted in which the pancreas specimens were obtained under cystoscopic direction during episodes of hypoamylasuria. The criteria for rejection episodes were not only biochemical abnormalities but also histologic confirmation and a follow-up to exclude other causes of graft dysfunction. Infectious disease management included use of oral selective bowel decontamination for 3 weeks after transplantation. At the Mayo Clinic between October 1987 and December 1988, 16 patients received pancreaticoduodenal allografts (both kidney and pancreas in 13 and pancreas only in 3 after a prior successful kidney transplantation). In two pancreas and one kidney allograft, function was lost. One patient died of multiorgan failure. The cystoscopically directed biopsy technique was performed 23 times with minimal complications and a 93% success rate. The metabolic results have been excellent; the glycosylated hemoglobulin level was normal 3 to 6 months after transplantation. The quality of life was significantly improved in almost all patients. Nutritional assessment revealed little deterioration after transplantation. With a multidisciplinary approach, the needed answers about the effect of pancreas transplantation on the degenerative complications of diabetes should be forthcoming.

Long-Term Follow-up Study of Periarteritis Nodosa.

Excerpt During the 16 years ending December 31, 1962, 130 patients with a histologic diagnosis of periarteritis nodosa were treated at the Mayo Clinic. The greatest incidence was in the fourth and ...

Splenectomy in high-risk primary renal transplant recipients

One hundred sixty-five high-risk patients who were either 50 years of age or older or had diabetes mellitus, or both underwent primary renal transplantation. One hundred eight had splenectomy and 57 did not. Graft and patient survival were analyzed in regard to whether splenectomy had been performed at all and whether it had been performed 30 days or more before transplantation, less than 30 days before, or at the time of transplantation. Also, the influence of age, diabetes, blood transfusions, blood type, donor type, HLA mismatch, pretransplantation dialysis, and percentage of performed antibodies were analyzed, as were complications and causes of death. Differences in patient survival were not significant in any one of these categories, although survival in the splenectomized group was generally better. The incidence of infection and sepsis was comparable in both groups and was responsible for death in 34 percent of the patients who underwent splenectomy compared with 22 percent of those who did not (no significant difference). Splenectomy improved cadaver donor renal allograft survival (p = 0.001) in the diabetic patients (p = 0.015) and in those 50 years of age or older (p = 0.026) but it did not improve survival in those who received living related donor kidneys. No significant differences were detectable in regard to the timing of splenectomy. The effect of splenectomy was significant in the patients who had not received transfusions (p = 0.003). It also improved survival in the transfused patients. Splenectomy in high-risk diabetic patients and patients 50 years of age or older does not seem to be associated with increased mortality.

Pancreas Transplantation at Mayo: I. Patient Selection

From October 1987 to December 1988, 59 patients underwent assessment for combined kidney and pancreas transplantation or pancreas transplantation after receiving a kidney allograft. We report our criteria for accepting candidates for transplantation, the results of the selection process, and the clinical and laboratory profile of those patients who underwent transplantation. Of the overall group, 22 patients (37%) were approved medically, 3 of whom were awaiting financial approval. Of the 59 patients, 15 (25%) were not approved for the transplantation program for medical reasons; in addition, 16 patients declined participation and 3 were not accepted because of lack of financial resources. Medical reasons for exclusion from pancreas transplantation were coronary artery disease in six patients, severe peripheral vascular disease in six patients, other medical problems in two patients, and noncompliance in one patient. Thus, many patients who underwent assessment for pancreas transplantation did not enter the program because of medical, financial, or personal preference reasons. In most cases, the medical reason for exclusion from pancreas transplantation was a cardiovascular disorder.