Sven-Erik Bergentz

Renal Artery Aneurysms: Natural History and Prognosis

Eighty-three patients out of 8,525 undergoing renal angiog-raphy during the years 1970–1979 were found to have renal artery aneurysm, which in six patients were bilateral and in 11 multiple. This corresponds to an incidence of almost 1% in this group of patients. Sixty-nine patients were treated conservatively and followed for a mean of 4.3 years. At that time nine patients had died. The cause of death was in no case related to the aneurysm. None of the 60 living patients had symptoms which could be related to the aneurysm. Reports of 36,656 autopsies, including most of the sudden deaths occurring in southern Sweden during a ten-year period, were analyzed. Nineteen cases of ruptured arterial aneurysms in the branches of abdominal aorta were found, but in no case were the renal arteries involved. It is concluded that the risk for rupture of a renal artery aneurysm is extremely small. The indications to operate renal artery aneurysms are discussed.

Solitary aneurysms of the iliac arterial system: An estimate of their frequency of occurrence * ** ***

Solitary iliac artery aneurysms are rare, and most reports have been presented as case reports. By combining autopsy records and operating records, a total of 13 cases were found: during a 15-year period (1971 to 1985), 42,010 of the inhabitants of Malmö died (population 230,000) and 35,265 (including 9014 forensic autopsies) underwent autopsy (84%). Solitary iliac artery aneurysms were found in seven (0.03%) of the 26,251 patients who underwent autopsy at the hospital; six of those had been asymptomatic and one was ruptured. Among the 9014 persons who underwent forensic medical autopsy, there were two with ruptured solitary iliac artery aneurysms. Four patients had clinically detected solitary iliac artery aneurysms, three of which were ruptured. All patients underwent surgery, and two of the three patients with ruptured solitary iliac artery aneurysms left the hospital well. The rupture rate of iliac aneurysm among those found at autopsy was one of seven (14%) and among those clinically detected three of four.

Effect of dextran on factor VIII (antihemophilic factor) and platelet function.

Three different properties of factor VIII (antihemophilic globulin) were studied after infusion of 500 ml of six per cent Dextran 70 to healthy volunteers. This dose caused no change in the factor VIII coagulant activity while there was a significant but temporary decrease of factor VIII related antigen. The Ristocetin induced platelet aggregation analysed with native as well as with formalin-fixed platelets, also decreased significantly. The maximal decrease was found a few hours after the infusion. The decrease was seen only if Dextran was infused in vivo and not if Dextran was added to blood in vitro. The dysfunction of factor VIII caused by Dextran resembles that found in one variant of von Willebrands disease. This finding probably explains the platelet function inhibiting properties of Dextran, and may be of significance for its antithrombotic effects.

The effect of dextran on the lysability of ex vivo thrombi.

The lysability was determined of thrombi formed in Chandler tubes before and after infusion of 500 ml dextran 70 to patients undergoing cholecystectomy. 125I-labelled fibrinogen was given the day before operation. Following incubation of the thrombi formed in plasmin, radioactivity remaining in the thrombi and released to the supernatant was determined, as well as fibrinolytic degradation products in the supernatant, using an immunoelectrophoretic method. The dextran infusion was found to increase the radioactivity released from the thrombi to the supernatant from 15.5 plus or minus 7.6% to a maximum of 27.3 plus or minus 8.2% four hours after the infusion (P less than 0.001). A corresponding significant rise of the FDP concentration in the supernatant from 16.8 mug/ml to 44.1 mug/ml was found at the same time. After 24 hours the radioactivity had returned to initial values. The results indicate that dextran infused into patients during surgery increases the lysability of thrombi. It is suggested that this finding at least partly explains the antithrombotic effect of dextran.

Long-term results after percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis—the importance of intensive follow-up*

The aim of this study was to investigate the long-term results of percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis (PTRA) in patients with renovascular hypertension with or without impending renal insufficiency who were followed up intensively with aggressive reintervention. Diagnostic work-up was based on angiography, pressure gradient and renal venous renin measurement. Patients were scheduled for regular follow-up after the PTRA and a deterioration in blood pressure or renal function was an indication for re-evaluation, and reintervention if necessary. Sixty-five patients had 71 renal artery stenoses where PTRA was attempted. It was technically successful in 59 stenoses and two occlusions and failed in ten (14%). At the end of follow-up (median 56 months [2-99]), the primary patency rate was 55%, 27 had restenosed and four were occluded, all but two within 12 months. Seventeen were treated by a further PTRA and eight by surgical reconstruction. At the end of follow-up the secondary patency after all interventions was 90%. One patient died 1 month after PTRA, and at the end of follow-up 21 patients (32%) had died, most of them (80%) from cardiovascular disease. Multivariate analyses showed a significantly reduced survival rate in patients with multiocular atherosclerosis, renal insufficiency, contralateral renal artery stenosis and ischaemic heart disease. At the end of follow-up 90% of the patients were cured or improved with regard to blood pressure. In patients with impending renal insufficiency renal function was improved in 50% and unchanged in 39%. With this strategy 55% of the patients needed only one treatment with PTRA, 25% needed a re-PTRA and 20% had to be operated on. PTRA can be recommended as initial treatment of atherosclerotic renal artery stenosis provided intensive follow-up and aggressive reintervention are performed when indicated.

Deep vein thrombosis after renal transplantation: a prospective analysis of frequency and risk factors

In a prospective study the frequency of deep vein thrombosis during the first 3 weeks after kidney transplantation has been evaluated using the combination of thermography and strain-gauge plethysmography for objective diagnosis. 83 consecutive patients were included, 33 with juvenile diabetes mellitus. The overall frequency of thrombosis was 24.1%, diabetes mellitus being a significant risk factor. No other risk factors were found. The transplant did not influence the venous outflow from the corresponding leg. Plasminogen activator activity in the iliac vein wall at transplantation did not differ between patients with and without thrombosis.

Chyluria treated with renal autotransplantation : a case report

We report a rare case of chyluria in a patient from an area not endemic to filariasis. Initial surgical treatment consisted of stripping of the renal pedicle, following which the patient was free of symptoms for 3 months. Recurrence was noted and renal autotransplantation was performed. Chyluria has not recurred 12 months after the second operation. The etiology and various treatments of chyluria are discussed.

Postoperative deep venous thrombosis after renal transplantation: effects of cyclosporine

In this prospective study the frequency of deep venous thrombosis during the first three weeks after renal transplantation was determined using a combination of strain gauge plethysmography and thermography for objective diagnosis. Ninety-seven consecutive patients were studied, 30 patients having juvenile diabetes mellitus. As immunosuppression cyclosporine and low-dose steroids were used. The series was compared with a similar group of 83 patients, 33 having juvenile diabetes mellitus treated with azathioprine and high-dose steroids as immunosuppression, in which the diagnosis of deep venous thrombosis was made with an identical technique. The overall frequency of thrombosis was 9.3% in the cyclosporine-treated group, which is a significant reduction in comparison with the azathioprine group (24.1%). It is concluded that the combination of cyclosporine and low-dose steroids does not increase the frequency of deep venous thrombosis in comparison with azathioprine and high-dose steroids in renal transplanted patients.

Kidney transplantation and fibrinolytic split products in serum and urine.

SUMMARY Fibrinolytic split products (FSP) in the urine and the serum were determined by a quantitative immunoelectrophoretic method in 28 recipients of a kidney and in nine living donors. Twenty patients were examined for urokinase activity in the urine. FSP invariably occurred in both the serum and the urine during the first 2 postoperative weeks in the recipients but not in the donors. This finding in the urine is probably attributable to the ischaemic injury to the transplanted organ. During acute or chronic rejection, FSP occur in the urine and sometimes also in the serum. During severe and irreversible rejection, the concentration of FSP in the urine is much higher than that in the serum. Separation studies on Sephadex G-200 showed that the FSP consisted mainly of “high molecular weight substances.” The urokinase activity in the urine from patients with transplanted kidneys was abnormally low, indicating that FSP are probably not formed by the activity of urokinase but rather by the fibrinolytic activity in the vessel walls.

The Cadaveric Kidney in Clinical Transplantation

(1) Forty-eight kidney transplants obtained from 37 cadaveric donors between 13 and 82 years of age were analyzed with regard to influence of donor age, warm and cool ischemia time, onset of function and later course. (2) Short warm ischemic period was of importance for early onset of function. Function was obtained after warm ischemic periods up to 60 minutes. (3) A simple perfusion technique with cool 5% Rheomacrodex solution was used and found effective to obtain a bloodless and cool state of the organ. (4) Cool ischemic period up to 7 hours was compatible with function and did not delay the onset of function. (5) Our method of preservation enabled kidneys to be transported from distant hospitals.