Takashi Yagisawa

Therapeutic Outcome of Primary Aldosteronism: Adrenalectomy Versus Enucleation of Aldosterone-Producing Adenoma

Our followup study of 48 patients with primary aldosteronism concerns the results of 2 different operative methods. After preoperative localization of the unilateral solitary tumor 22 patients underwent unilateral adrenalectomy and 26 underwent enucleation of aldosterone-producing adenoma. Both operative methods improved hypertension, hypokalemia, the low urinary sodium-to-potassium ratio, suppressed plasma renin activity, high plasma aldosterone concentration, high urinary aldosterone excretion and high urinary kallikrein excretion in similar orders of magnitude for 5 years. Levels of plasma cortisol and plasma adrenocorticotropic hormone following respective operations were also identical. Five years postoperatively, ambulation and furosemide administration under low sodium diet stimuli remarkably enhanced plasma renin activity and plasma aldosterone concentration in the aldosterone-producing adenoma enucleation group (p < 0.001), almost similar to that of normal subjects but increment magnitudes were slight (p < 0.05 to < 0.01) in the adrenalectomy group. Preoperatively, angiotensin II infusion failed to increase plasma aldosterone concentration in patients with primary aldosteronism. After respective operations, responses of plasma aldosterone concentration to angiotensin II infusion and of plasma cortisol to adrenocorticotropic hormone administration in the aldosterone-producing adenoma enucleation group were more sensitive than those in the adrenalectomy group. There was no remission of recurrent hyperaldosteronism in either group throughout the study. These results suggest that angiotensin II induces aldosterone release by an activation of tumor uninvolved cortical cells and that the enucleation of aldosterone-producing adenoma is more preferable than unilateral adrenalectomy.

Acute Hemorrhagic Cystitis Caused by Adenovirus after Kidney Transplantation

We report on 10 kidney transplant patients with acute hemorrhagic cystitis caused by adenovirus, accompanied by the deterioration of kidney function. They developed macrohematuria with urgency, frequency and micturition pain for more than 7 days within 1 year after transplantation. Adenovirus type 11 was isolated from the urine of 6 patients, and complement-fixing antibody became positive in 9 patients. Hematuria and irritative voiding symptoms disappeared without any specific treatment; however, serum creatinine rapidly increased. The histological findings of the biopsy specimens indicated that renal impairment was attributed to acute rejection in some cases and virus-associated nephropathy in other cases. Acute hemorrhagic cystitis caused by adenovirus is an interesting complication after kidney transplantation, especially with regard to kidney impairment and treatment.

REMARKABLY SUPPRESSED MANGANESE SUPEROXIDE DISMUTASE ACTIVITY IN MALIGNANT PHEOCHROMOCYTOMA

There are almost no special histopathological characteristics or criteria that exactly define a malignant pheochromocytoma. Tissue concentrations of catecholamine metabolites and superoxide dismutase activity have been proposed as possible candidates for discriminating between benign and malignant pheochromocytomas. Tissue concentrations of dihydroxyphenylalanine, metanephrine, normetanephrine, vanillylmandelic acid, and 3-methoxy-4-hydroxyphenylethylglycol were determined in 29 normal adrenal medullas, 13 benign pheochromocytomas and 6 malignant pheochromocytomas, respectively. The copper-zinc superoxide dismutase and manganese superoxide dismutase activities in remnants of these tissues were determined by interruption of nitric formation from hydroxylamines. Catecholamine metabolites and copper-zinc superoxide dismutase activity in benign and malignant pheochromocytomas were identical. Manganese superoxide dismutase activity in malignant pheochromocytoma was the lowest among the groups examined. These data suggest that the assay of catecholamine metabolites in removed specimens is not a reliable method for making a differential diagnosis of benign or malignant pheochromocytoma. However, a low level of manganese superoxide dismutase activity in malignant pheochromocytoma may be a marker for malignancy of this neoplasm.

Efficacy of Enalapril after ineffective theophylline treatment on erythrocytosis after renal transplantation

Erythrocytosis represents a common complication in renal allograft recipients. Traditional therapies including phlebotomy and bilateral native nephrectomies are cumbersome for both the clinical personnel and the patient. Recently, pharmacological agents such as angiotensin converting enzyme inhibitor and theophylline have been proposed as effective therapies for post-transplant erythrocytosis (PTE). We have treated a PTE patient successfully with enalapril without any side effects and renal dysfunction after theophylline treatment showed no improvement in PTE. A decline in Ht levels was independent of the changes in Epo levels during enalapril treatment. Although the mechanism underlying the beneficial effect of enalapril remains undetermined, enalapril is recommended for the initial treatment of PTE.

Successful renal autotransplantation with Y-prosthetic aortic replacement in a patient with complete occlusion of abdominal aorta and renal artery.

Occlusion of the abdominal aorta represents the end stage of an atherosclerotic process and often is associated with stenosis of renal artery inducing renal failure and hypertension. Surgical and medical treatments are indicated to preserve and restore renal function in patients with these conditions. We report herein the first successful renal autotransplantation combined with aortic replacement by Y prosthesis in a patient with complete occlusion of abdominal aorta and bilateral renal arteries, resulting in limb-threatening ischemia and progressive renal failure.

Cytomegalovirus-associated hepatitis and duodenal ulcer in kidney allograft recipients

We report here on two patients with kidney allografts who had hepatitis and duodenal ulcer caused by cytomegalovirus. In one case, hepatosplenomegaly and jaundice appeared after high fever lasting for ten days. Laboratory examinations showed liver dysfunction and lymphocytosis with atypical forms. Virological studies revealed cytomegalovirus infection and we successfully treated the patient with human interferon-β. In the other case, duodenal bleeding followed by interstitial pneumonia occurred at the 54th day after transplantation. Bleeding from the small duodenal ulcer did not stop in spite of conservative and endoscopic therapies, and gastrectomy was performed. Histologically many epithelial cells with intranuclear inclusions were found around the ulcer. Virological studies showed elevation of antibody titres to cytomegalovirus which was isolated from the urine and oropharyngeal secrete. After gastrectomy and treatment with ganciclovir, the general condition improved and graft function was maintained. Our experience with these cases suggests that aggressive diagnostic investigations for cytomegalovirus infection are essential in patients with organ allografts who present liver and gastrointestinal lesions.

Surgical repair of aneurysm in the transplanted kidney following a percutaneous needle biopsy.

Arterial aneurysm following a needle biopsy is a serious and troublesome complication in renal allograft. We report herein a case in which the large aneurysm developed at the interlobar arterial branch in the transplanted kidney after needle biopsy. We also present the successful surgical treatment of the aneurysm and discuss the management of this complication.

Removal of Large Adrenal Tumor on the Right Side with Liver Mobilization

Twenty-one patients with large adrenal tumor on the right side were operated on at Yamagata University Hospital. Bilateral anterior subcostal incision with a vertical midline incision extending from the xiphoid and subsequent use of self-retraction system provided satisfactory exposure of anterior liver and diaphragma area. Successive retraction of the liver exposed the right adrenal tumor and its vascular pedicles. 14 (66.7%) of the 21 patients received right adrenalectomy with liver mobilization, and 7 (33.3%) received right adrenalectomy without mobilizing the liver. Despite the average weight of removed tumors was 152.9% (p < 0.01) greater in the liver mobilized group than in the liver nonmobilized group, the incidence of good exposure of right adrenal central vein including adjacent organs was higher in the former group. In addition, incidence of blood transfusion was identical in both groups. Although postoperative liver function was slightly impaired in the liver mobilized group as compared with the liver nonmobilized group, all examined valuables manifesting liver function in the former group returned to preoperative levels within 3 weeks. The operative procedure described above appears to be useful for the removal of right large adrenal tumors with less risk of serious accident.

EARLY STEROID WITHDRAWAL AFTER KIDNEY TRANSPLANTATION

BACKGROUNDnThe side effects of steroid are serious problems in renal transplant patients. However, withdrawal of steroid has been controversial. We evaluated the benefits and risk of early steroid withdrawal after renal transplantation.nnnPATIENTS AND METHODSnThe outcomes of early steroid withdrawal from triple immunosuppressive drug therapy were analyzed in four living related and one cadaveric renal transplant recipients. The dosage of steroid was gradually reduced and the time of steroid withdrawal after transplantation was 5 to 7.5 months.nnnRESULTSnFour Patients have been able to be free from steroid and maintained stable graft functions and normal urinary findings for 14 to 33 months after withdrawal. The findings of rejection were not observed in the graft specimens obtained by serial biopsies. One patient who received a living related graft developed an increase in serum creatinine level and proteinuria two weeks after discontinuation of steroid. The serum creatinine level returned to that before withdrawal and proteinuria disappeared by steroid readministration. Long term side effects of steroid were not observed in 4 patients with successful steroid withdrawal.nnnCONCLUSIONnThese results suggest that steroid withdrawal about 6 months after transplantation can be accomplished without jeopardizing graft function in selected renal transplant recipient and the withdrawal in the early stage is preferred for reducing the side effects. Careful and long-term follow up are required to assess the further risk and benefit of steroid withdrawal on immunosuppressive morbidity.

Successful steroid withdrawal half a year after kidney transplantation

We report two kidney transplant recipients with successful steroid withdrawal. They are living related donor transplant recipients. The first patient, a 37-year-old female, received the kidney from her HLA identical father. The second patient, a 44-year-old man, received the kidney from his HLA 1 haploidentical brother. Both patients were maintained on triple immunosuppressive drug therapy pior to withdrawal of steroid and subsequently were maintained on cyclosporine and azathioprine or mizoribine. Acute rejection occurred within the first 1 month and was treated with steroid bolus therapy successfully in both cases. The time of steroid withdrawal after transplantation was 6.5 months in the first patient and 5 months in the second patient. After steroid withdrawal their graft function remained stable and the graft specimens obtained by biopsy 8 months after withdrawal showed no signs of rejection; no side effects of steroid appeared. These results suggest that steroid withdrawal half a year after transplantation can be accomplished without jeopardizing graft function in selected living related donor transplant recipients.