William Nylander

Living related kidney donors: a 14-year experience

Living related donor (LRD) nephrectomies are controversial due to the risks to the donor and improved cadaveric graft survival using cyclosporine A. Between December 22, 1970, and December 31, 1984, 1096 renal transplants were performed at a single institution, 314 (28.6%) from LRD. The average age was 34.3 years (range: 18-67); none had preoperative hypertension. All nephrectomies were performed transabdominally. Major perioperative complications occurred in 22 (7.0%). These include wound infections (3.5%), pancreatitis (1.0%), injuries to spleen (1.0%) or adrenal gland (0.3%) requiring removal, pneumonitis (0.6%), ulnar nerve palsy (0.6%), femoral artery thrombosis after arteriogram (0.3%), pulmonary embolus (0.3%), and upper pole infarct of contralateral kidney (0.3%). There are six known deaths in this series, none of which were related to the operation. Major late complications were seen in 50 (20.0%) of 250 patients followed for 6 to 175 months (mean 53.1 months). These included definite hypertension (5.6%), suture granuloma (4.4%), incisional hernia (3.6%), proteinuria (2.4%), bowel obstruction (2.0%), nephrolithiasis (1.2%), wound infection (0.4%), scrotal hydrocele (0.4%), and chronic pancreatitis (0.4%). While the risk of hypertension appears to increase as the interval from donation increases, no cases of renal failure after donation have been noted, and negligible proteinuria among those followed long-term has been seen in this series. It is felt that living related kidney donation is justified when the relative is sincerely motivated and well informed prior to donation.

Thiopental Modification of Ischemic Spinal Cord Injury in the Dog

Spinal cord ischemia was produced in male mongrel dogs by permanent occlusion of the infrarenal aorta. All animals were anesthetized with a mixture of nitrous oxide and 1.5% halothane. Group 1 animals were the controls. Group 2 animals were pretreated, 30 minutes prior to aortic occlusion, with sodium thiopental, 20 mg per kilogram of body weight, over 5 minutes, followed by an infusion of 10 mg/kg/hr for 2 1/2 hours. Groups 3 animals received the identical dose of sodium thiopental and, in addition, received mannitol, 1 gm/kg, and methylprednisolone 1 mg/kg. There were no differences in hemodynamic data or arterial blood gases among the groups, except that the thiopental bolus caused a transient reduction in mean arterial pressure. Ninety percent of Group 1 animals were paraplegic, while only 30% of Group 2 and 40% of Group 2 animals were paraplegic. The difference in the incidence of paraplegia in Groups 2 and 3 compared with Group 1 was statistically significant (p less than 0.05). Therefore, thiopental significantly decreased the incidence of paraplegia, while methylprednisolone and mannitol did not enhance its protective effect.

A pilot protocol of a calcineurin-inhibitor free regimen for kidney transplant recipients of marginal donor kidneys or with delayed graft function

Abstract: Background: The worsening shortage of cadaver donor kidneys has prompted use of expanded or marginal donor kidneys (MDK), i.e. older age or donor history of hypertension or diabetes. MDK may be especially susceptible to calcineurin‐inhibitor (CI) mediated vasoconstriction and nephrotoxicity. Similarly, early use of CI in patients with delayed graft function may prolong ischaemic injury. We developed a CI‐free protocol of antibody induction, sirolimus, mycophenolate mofetil, and prednisone in recipients with MDK or DGF.

Biotin transport in the human intestine: Site of maximum transport and effect of pH*

Previous studies from our laboratory have characterized the transport process of biotin across the brush border membrane and the basolateral membrane of the human intestine. In this study we further characterized biotin transport in the human intestine by examining the vitamins transport process in different areas of the small intestine (duodenum, jejunum, and ileum) and the effect of pH on the transport process using a brush border membrane vesicle technique. In all areas examined, the transport of biotin as a function of concentration was saturable in the presence of a Na+ gradient (out greater than in) but was linear and lower in the presence of a choline gradient (out greater than in). Transport of biotin by the Na+-dependent process (i.e., the carrier-mediated process) was found to be higher in the duodenum than the jejunum, which was in turn higher than that in the ileum. This decrease in biotin transport distally was found to be due to a decrease in the Vmax of the transport process of the vitamin with no changes in the apparent Km. This indicates that the number (i.e., the density) of transport carriers for biotin decreases distally. In the presence of a Na+ gradient (out greater than in), decreasing incubation buffer pH from 8.0 to 5.5 (intravesicular pH was 7.4) was found to cause an increase in biotin transport. This increase was found to be due to the acidic buffer pH (i.e., not due to the pH gradient imposed across the membrane) and occurred through an increase in the transport of the vitamin by the nonmediated process. These results demonstrate that the proximal part of the small intestine is the site of maximum transport of biotin in humans. Furthermore, variation in incubation medium pH affects biotin transport through changes in the substrate transport by the nonmediated process.

Biotin transport in basolateral membrane vesicles of human intestine

The characteristics of the exit process of biotin from the enterocyte, i.e., transport across the basolateral membrane, was determined using an enriched basolateral membrane vesicle preparation of human intestine. Purity and suitability of basolateral membrane vesicles for transport studies was confirmed by enzymatic and functional criteria. Orientation of human basolateral membrane vesicles was determined by [3H]ouabain binding studies and was found to be 64% inside-out vesicles and the rest right-side-out vesicles and membrane sheets. Osmolarity studies indicated that the uptake of biotin by these vesicles represents transport into the intravesicular compartment, with little binding to membrane surfaces. The rate of biotin transport was linear for approximately 40 s but decreased thereafter. Transport of biotin was (a) Na+-independent, (b) saturable as a function of concentration, with an apparent KM of 1.1 microM and Vmax of 0.9 pmol/mg protein.15 s, (c) inhibited by structural analogues (desthiobiotin and biotin methyl ester) and related compounds (thioctic acid and thioctic amide), and (d) stimulated by inducing a positive intravesicular electrical potential. These studies are the first to demonstrate the existence of a carrier-mediated transport system for biotin in the basolateral membrane of human intestine.

Polyclonal antibody-induced serum sickness in renal transplant recipients: treatment with therapeutic plasma exchange.

Serum sickness is an immune-complex mediated illness that frequently occurs in patients after polyclonal antibody therapy (ATGAM or thymoglobulin). Serum sickness presents with significant morbidity but is self-limited and resolves with prolonged steroid therapy. We present five renal transplant patients who developed serum sickness after polyclonal antibody treatment with severe symptoms that persisted after being started on systemic steroids. These patients underwent one or two courses of therapeutic plasma exchange (TPE) with subsequent complete resolution of their symptoms. Renal transplant recipients with serum sickness after polyclonal antibody therapy may benefit from TPE by accelerating their time to recovery and thereby reducing overall morbidity.

Care pathway reduces hospitalizations and cost for hemodialysis vascular access surgery

Hemodialysis vascular access-related hospitalizations account for more than 20% of United States end-stage renal disease (ESRD) hospitalizations, with an annual cost approximating

Disseminated Histoplasmosis Presenting as Urinary Tract Obstruction in a Renal Transplant Recipient

675 million. Limiting access-related costs while delivering similar degrees of quality care thus would enhance alternative utilization of ESRD funding. We implemented a vascular access care pathway emphasizing coordinated patient evaluation and outpatient surgery to determine whether such an intervention affected outcomes associated with vascular access surgery. Data examining hospitalization and vascular access surgery charges, complications, and patient satisfaction (determined by questionnaire) were analyzed, comparing patients who underwent vascular access surgery in 1994 and 1995 as inpatients (non-care pathway patients) and patients who underwent vascular access surgery via the care pathway in 1995. Inpatient days declined in 1995 (1994: 582 days; 1995: 85 days; P < 0.03) and the average charges per patient for the care pathway cohort were significantly less than charges per patient in 1994 and charges for non-care pathway patients in 1995 (1994 patients:

Characterization of calcium uptake by brush border membrane vesicles of human small intestine

10,524 +/-

Patient education level affects functionality and long term mortality after major lower extremity amputation

5,209; 1995 non-care pathway patients: