Satoru Nakamoto

Lymphoceles associated with renal transplantation: Report of 15 cases and review of the literature

Abstract Within a 27 month period (from July 1, 1971 to October 1, 1973), during which 83 renal allotransplantations were performed at the Cleveland Clinic, a lymphocele developed in 15 patients (18.1 per cent). Early clinical symptoms, occurring within 6 weeks after transplantation, were suprapubic or lower abdominal swelling in 14 patients, leg swelling ipsilateral to the allograft in 12, nonpitting edema in the allograft area in 10 and lymph drainage from the wound in 8. An intravenous pyelogram demonstrated a lymphocele in 13 patients from 1 to 34 weeks after transplantation (mean 7.8 weeks), although an earlier suggestion of bladder displacement and deformity was found retrospectively in 5 patients between 1 and 3 weeks after transplantation. Lymphangiograms aided in the diagnosis in nine patients. The major complication of the lymphoceles was obstructive uropathy that developed in nine patients between 2 and 34 weeks after transplantation (mean 10.3 weeks). Lymphoceles mimicked rejection, urine extravasation, pyelonephritis, thrombophlebitis and a seroma, and occurred concurrently with rejection and pyelonephritis. Treatment by external surgical drainage was more effective than aspiration both in resolving the lymphocele and in avoiding infection. Three lymphoceles drained spontaneously 1 to 2 weeks after transplantation, and three are under observation. Chemical and protein analyses were made of the lymphocele fluid obtained from seven patients. Numerous factors may contribute to the formation of a lymphocele by increasing lymph flow. The most prominent factors are the extent of surgical dissection, the occurrence of rejection, and the use of diuretics, large doses of corticosteroids, and anticoagulants. The literature on lymphoceles in renal allograft recipients is reviewed, and pertinent comparisons are made with the more numerous reports of lymphoceles in nontransplant patients.

Uremic Pericarditis and Cardiac Tamponade in Chronic Renal Failure

Excerpt Uremic pericarditis has long been regarded as a sign of impending death (1-4). Since the introduction of intermittent dialysis and renal transplantation, the outlook for the uremic patient ...

Concomitant Hepatitis B Surface Antigen and Antibody in Thirteen Patients

Both hepatitis B surface antigen (HBsAg) and its antibody (anti-HBs) were found in 13 patients. Nine patients had HBsAg subtype ad, and 7 had anti-HBs monotypic subtype anti-y. Nine patients had HBsAg before detectable levels of anti-HBs were present. Of the 6 patients whose serum contained subtypes of both HBsAg and anti-HBs, 4 had HBsAg before development of the monotypic antibody. All patients have remained positive for HBsAg and anti-HBs (mean duration, 55.5 weeks). Nine patients were positive for HBeAg, and 7 had renal disease. Six of these seven patients are on hemodialysis. Because of the differing subtype specificities of the circulating HBsAg and anti-HBs, we conclude that HBsAg and anti-HBs occur concomitantly. The presence of HBeAg, which indicates infectivity, is common in our study group, suggesting that these patients are a reservoir for transmission of hepatitis-B-virus infection. Therefore, the presence of anti-HBs alone does not indicate a noninfectious serum. Concomitant HBsAg and anti-HBs seems to be particularly common in patients with renal disease who are on hemodialysis.

Effect of Bilateral Nephrectomy and Kidney Transplantation on Hypertension in Man

In conclusion, we consider that renal hypertension may have two components: a renal component and a renoprival component (fig. 6). Bilateral nephrectomy abolishes the renal component and leaves a renoprival hypertension that is sensitive to water and salt. Implantation of a kidney may cure the renoprival hypertension. Rejection of the graft may then be followed by a return of renal hypertension. Since the technique of transplantation of kidneys taken from cadavers is improving steadily, repeated nephrectomies and a second transplant become possible.

Renal Homotransplantation in 24 Patients

There are now in the world about 30 patients who have lived longer than one year after homotransplantation from donors other than identical twins (Murray, personal communication, 1964). Several centres in Europe and the United States have made outstanding contributions to the clinical field, and encouraging results have been reported by Hume et al. (1963), Merrill et al. (1963), Shackman et al. (1963), Woodruff et al. (1963), and Starzl et al. (1964a). Results obtained at the present time indicate that useful prolongation of life is possible in from 30 to 50% of patients having terminal renal failure. Between January 1963 and June 1964 27 renal transplantations were performed on 24 patients at the Cleveland Clinic (Table I). Six cases have been reported in detail (Figueroa et al., 1964). As this is a rapidly advancing field we believe it is appropriate to analyse our results and draw preliminary conclusions for future guidance.

Acute effects of hemodialysis on echographic-determined cardiac performance: Improved contractility resulting from serum increased calcium with reduced potassium despite hypovolemic-reduced cardiac output

The hemodialysis session leads to reduction in circulating blood volume (TBV) and arterial pressure (BP) plus correction of electrolyte imbalance. The effect of these alterations on cardiac performance was evaluated in 18 patients with end-stage renal disease. Hemodialysis for 5 hours led to significant reduction (p less than 0.001) in weight TBV, and BP. Neither ejection fraction nor percentage fiber shortening was altered, whereas mean velocity of circumferential fiber shortening (mean VCF) and mean systolic ejection rate (MSER) were both significantly increased (1.17 +/- 0.20 to 1.38 +/- 0.28 circ/sec and 2.38 +/- 0.27 to 2.80 +/- 0.40 EDV/sec, respectively; p less than 0.001 for each). Since both venous return and systolic BP were decreased, increase in velocity of ventricular contraction implies enhancement of cardiac performance beyond what would be expected from alterations in ventricular filling and resistance to ejection. This enhancement is possibly related to concomitant reduction in serum potassium (p less than 0.001) and increase in serum calcium (p less than 0.005) achieved by hemodialysis.

Treatment of Oliguric Glomerulonephritis with Dialysis and Steroids

Excerpt The prognosis of acute glomerulonephritis with severe or prolonged oliguria is grave (1-7). Repeated hemodialyses are justified for at least 6 weeks, to allow time for diuresis to occur (7)...

HEMODYNAMICS OF ISOLATED ULTRAFILTRATION IN CHRONIC HEMODIALYSIS PATIENTS

Six patients on maintenance hemodialysis were investigated by direct determination of hemodynamic changes induced by UF. Our results show: 1. Despite a significant fall in ECF and PV, the PV/IF ratio was unchanged indicating absence of major fluid shifts between intravascular and extravascular compartments. 2. The rise in CPV/TBV ratio observed indicates central redistribution of intravascular fluid suggesting venoconstriction. 3. CPV and hence CO was maintained so that a stable MAP resulted.

The fate of renal allografts functioning for a minimum of 20 years (level 5A)--indefinite success or beginning of the end? A proposed classification of long-term allograft survivals.

Fifty-five renal allografts (44 from living-related and 11 from cadaver donors) that have functioned for at least 20 years (mean 22.9×2.3, range 20.1 to 30.7 years) were evaluated in three groups based on renal function: group I (n=26), with a GFR of ≥60 ml/min/1.73 m2 or serum creatinine ≤1.4 mg/dl and no proteinuria; group II (n=9), with a GFR of ≥60 ml/min/1.73 m2 or serum creatinine ≤1.4 mg/dl but <150 mg protein-uria/24 hr; and group III (n=20), with a GFR <60 ml/ min/1.73 m2 and/or serum creatinine >1.4 mg/dL with or without proteinuria. Allograft factors, including acute rejection (AR) in 62% (34/55) and delayed function (DF) in 55% (6/11) of the cadaver grafts, did not preclude 20-year success and the prospect of continued survival since they were not significantly more frequent in group I, II, or III. However, AR was confined to a limited period within the first three months posttransplant in 18/18 recipients in groups I and II but only in 7/16 of group III (P=0.0002). In groups I and II AR was treated with IVMP in 14/18 cases and only 6/16 in group III (P=0.035). Donor age ≤50 years and recipient age ≤40 years each occurred in 87% (48/55) of these transplants. One- or two-HLA haplotype matching was present in 98% (43/44) of living related transplants. Major risks to the recipient were coronary artery disease (11 cases and 3 deaths), malignancy (18 cases and 1 death), and severe infection and hepatitis (35 cases and 3 deaths, 2 of whom also had coronary artery disease). Hypertension occurred in 25 recipients and diabetes mellitus in 12. Potential open-end success was compromised by renal dysfunction in groups II and III, but appeared possible in 12 of the 26 patients in group I. There is no apparent “safe-haven” point of time for immunosuppressed renal allograft recipients, who remain at increased risk for eventual renal allograft dysfunction, as well as cardiovascular, neoplastic, infectious, and metabolic diseases. In order to clarify and standardize the words “long-term,” a simple classification of long-term allograft survivals is proposed.

Comparison of renal transplantation and dialysis in rehabilitation of diabetic end-stage renal disease patients

We have reviewed the outcome of replacement therapy for end-stage renal disease (ESRD) in 100 diabetic patients with emphasis on late complications, extrarenal diabetic manifestations, and overall patient rehabilitation. Long-term complications, other than myocardial infarction, were not different after renal transplantation compared with chronic dialysis. Overall rehabilitation was better after renal transplantation compared with chronic dialysis (p less than 0.05). Retinopathy and neuropathy were more stable with renal transplantation and peritoneal dialysis compared with hemodialysis (p less than 0.05). These factors should be considered along with expected patient survival when deciding between different treatment modalities for diabetic ESRD.