Kidney transplantation in insulin dependent diabetic patients: improved survival and rehabilitation

Between 1977 and 1986, 50 insulin-dependent diabetic patients received a kidney transplant, 19 from living related donors and 31 from cadaveric donors. Cumulative patient survival was 81% and graft survival was 64% and 33% for living related and cadaveric donor kidneys, respectively, at five years. These results are comparable to that of nondiabetic patients. While physical performance and visual acuity significantly improved after a successful kidney transplantation, neuropathies and angiopathies might not improve. Physical performance improved even in those patients whose nerve conduction time had deteriorated. These findings suggest that kidney transplantation is an effective means of improving survival and rehabilitation of diabetic patients with end-stage renal disease.

[Liaison psychiatry: a new perspective on mental health in Latin America]

The situation of Mental Health in Latin America is analyzed. Urgently creating a system able at handling the psychiatric disease increase in the years to come is a conclusion this paper strongly aims at. The beginning of Psychiatry is reviewed, and the importance of Psychiatry at the General Hospital is outlined as well as its rapprochement toward the community, which led to a better control and prevention in the field of Mental Health. A definition of Psychiatry is proposed, as a branch of Medicine which stands in between mental hospitals and communities. Active teamwork, coupled with the physician's work and the tasks other members of the health personnel are engaged in, has led to a more integrated approach onto the ill thus benefiting not only patients but also the whole community.

Photosynthetic Gas Exchange Characteristics of Wheat Flag Leaf Blades and Sheaths during Grain Filling: The Case of a Spring Crop Grown under Mediterranean Climate Conditions

The rate of net CO(2) assimilation (A), the stomatal (g(s)) and residual (g(r)) conductances to CO(2), the intercellular CO(2) concentration, the CO(2) compensation points at 21% O(2) (Gamma(21)) and at 2% O(2) (Gamma(2)), and the amounts of dry matter, nitrogen, and carbohydrates were determined, from anthesis through grain filling, in the flag leaf blade and sheath of spring wheat (Triticum aestivum L. cv Kolibri). The nitrogen content and the rate of net CO(2) assimilation declined slowly until the onset of senescence in both organs, about 3 weeks after anthesis. During senescence the reduction of A in both organs was not primarily caused by a decrease in g(s); the main factor is the decrease in g(r). From values of Gamma(21) and Gamma(2) it is suggested that the rate of respiration in the light contributing to the CO(2) compensation point is higher in sheaths than in blades irrespective of the O(2) level considered. The role of sheaths storing and later transporting assimilates to the developing grains seems to be more important for shoot yield than that of sheaths functioning as photosynthetic organs after the onset of senescence occurs. It is suggested that accumulation of carbohydrates in leaves might somehow trigger senescence in the flag leaf blade and sheath simultaneously.

Invasive trichophyton rubrum infection in an immunocompromised host. Case report and review of the literature

Typically confined within the keratinized, epithelial layer of the skin and hence categorized among the dermatophytoses, Trichophyton rubrum infections usually present as superficial, scaling eruptions. In certain clinical settings, however, such as in immunosuppressed hosts, deep local invasion, multivisceral dissemination, and even death due to T. rubrum granulomas have been described. A case of multiple, subcutaneous, neutrophilic abscesses due to T. rubrum in an immunosuppressed renal allograft recipient is described. The pathogenesis, diagnosis, and immunology of invasive T. rubrum infections in immunocompromised hosts are reviewed.

Ontogenetic changes in photosynthetic capacity and dry matter production of flag wheat leaves during the grain filling period

The relationships between photosynthetic capacity and dry matter accumulation during the grain filling period have been studied in flag leaves of Triticum aestivum L., cv. Kolibri grown in Mediterranean field conditions. Particular importance has been given to assimilate accumulation in relation to the onset of senescence. During grain filling, the time course of specific dry weight (SDW) was similar in the blade and in the sheath. Variations in SDW were about six times larger in the sheath than in the blade. Minimum blade SDW values occurred during heading and at anthesis. Maximum blade SDW values were observed two weeks after anthesis. After this, SDW values decreased sharply. The dry matter increase per grain in the period from two weeks after anthesis to the end, was only about 25% of final grain dry weight. The importance of environmental constraints on maximum SDW values are discussed. Maximum SDW values occurred at the beginning of the period of rapid decline in blade net CO2 assimilation rate and leaf nitrogen content, that is, at the beginning of senescence. On the other hand, the stomatal resistance to CO2 and the development of senescence are not apparently related. The maximum blade dry weight increase (considering a value of zero at heading) was about 60 mg dry weight per g fresh weight. The possible relationships between dry matter accumulation and senescence onset are discussed.

Focal segmental glomerulosclerosis in renal transplants

This is a study of the incidence and clinicopathological significance of focal segmental glomerulosclerosis (FSG) in 154 renal allografts (22 biopsies, 128 nephrectomies and four necropsies) from 137 cadaveric and 17 living-related donors. FSG was identified in 18 grafts (11.7%) from 16 patients: six as recurrent FSG in four patients (two developed FSG in two consecutive transplants) and 12 as de novo FSG. The incidence of recurrent FSG in patients who had FSG as their original kidney disease was 30.8% whereas that of de novo FSG in patients who had renal diseases other than FSG was 8.7%. Histologically, recurrent FSG was characterized by mild degrees of obliterative arteriopathy of rejection and preferential involvement of the juxtamedullary glomeruli. Whereas, in de novo FSG, the occlusive vascular changes of rejection were severe and the glomeruli in the outer cortical region were mostly involved. Clinically, however, the differences between them were less clear, although nephrotic syndrome tends to occur more often and earlier in patients with recurrent FSG. Obliterative arteriopathy of chronic rejection and consequent glomerular ischemia appeared to be of major importance in the pathogenesis of de novo FSG in renal allografts.

Percutaneous transluminal dilation in renal transplant arterial stenosis

Twelve hypertensive patients underwent percutaneous transluminal dilation (PTD) for relief of arterial stenosis complicating renal allotransplantation. Two patients underwent repeat PTD for recurrent stenosis and hypertension. Six patients had end to end anastomosis of the donor renal artery to the recipient hypogastric artery; four of six PTDs were successful. Six patients had end to side anastomosis of the donor renal artery to the recipient external iliac artery; seven of eight PTDs, including one of two repeat PTDs, were successful. Prior to PTD, all patients were using several antihypertensive medications. Following successful PTD, the mean blood pressure dropped from 184 +/- 15/118 +/- 9 to 133 +/- 13/89 +/- 11 mm Hg (P < 0.001) and remained at that level for up to 15 months (average followup 9 months) with decreased or no antihypertensive medications. Since surgical correction of arterial stenosis occurring after renal transplantation is difficult and may endanger the graft, PTD should be the first interventional therapy.

Kidney transplant nephrotic syndrome: relationship between allograft histopathology and natural course

We analyzed clinical and pathologic data from 36 recipients of 38 renal allografts who developed nephrotic syndrome following transplantation. Three groups were identified on the basis of histologic changes in the graft, and each group had a distinct clinical course. Nine grafts (23.7%) had recurrent glomerulonephritis (GN) (5 membrano-proliferative, 4 focal glomerulosclerosis) and developed nephrotic syndrome at 5.1 months (mean) posttransplant. Renal function deteriorated rapidly, with a 2-year graft survival of 29.7%. Four grafts (10.5%) with de novo GN (3 epimembranous, 1 minimal change) developed nephrotic syndrome at 32 months posttransplant, and all functioned for more than 3 years. Twenty-five grafts (65.8%) had allograft glomerulopathy with the onset of nephrotic syndrome at 9.1 months posttransplant and a 2-year graft survival of 66.6%. The differences in duratin of graft function between grafts with allograft glomerulopathy and recurrent GN (P < 0.01) and in graft survival rates at 2 years among the three groups (P < 0.05) are statistically significant. This analysis indicates that allograft glomerulopathy is the most common cause of kidney transplant nephrotic syndrome. Membranoproliferative GN and focal glomerulosclerosis may recur soon after transplantation and rapidly progress to renal failure in marked contrast to grafts with either de novo epimembranous nephropathy or minimal glomerular change, lesions that are compatible with prolonged graft function.

Percutaneous transluminal angioplasty in renal transplant arterial stenosis for relief of hypertension

Seven hypertensive patients underwent percutaneous transluminal angioplasty (PTA) for relief of arterial stenosis complicating renal allotransplantation. Four had end-to-end anastomosis of the donor renal artery to the recipient hypogastric artery; all PTA's were successful. Three patients had end-to-side anastomosis of the donor renal artery to the recipient external iliac artery; 2/3 PTA's were successful. Prior to PTA, all patients were using several antihypertension medications. Following successful PTA, the mean blood pressure fell from 190 +/- 10/120 +/- 5 to 132 +/- 16/86 +/- 9 mm Hg (p less than 0.01) and remained at that level for up to six months (average follow-up 2.85 months) with decreased or no antihypertension medications. Since surgical correction of arterial stenosis is difficult and may endanger the transplant kidney, PTA should be attempted first.

Association between Streptococcus faecalis urinary infections and graft rejection in kidney transplantation

In the first month after transplantation 50% of 193 consecutive renal transplant recipients had bacteriuria. The most common organisms isolated were Streptococcus faecalis (34), Escherichia coli (28), Pseudomonas spp. (11), and staphylococcus (9). There was a significant correlation between infection with Str. faecalis and graft failure at one, three, and twelve months. This observation suggests that urinary infection with Str. faecalis may be associated with graft failure which is probably the result of immunological factors.

Anaerobic bacteriuria in renal transplantation

Renal allograft recipients were studied prospectively utilizing improved culture techniques to investigate anaerobic bacteriuria. The study population was compared with a population of patients with chronic renal insufficiency and end stage renal disease. The over-all incidence of anaerobic urinary tract infection was 7.5 per cent while the over-all incidence of aerobic urinary tract infection was 23.5 per cent. Patients with cadaver renal transplants during the early postoperative period had the highest incidnece of both anaerobic (42.9 per cent) and aerobic (71.4 per cent) urinary tract infection of all groups. The potential association between significant anaerobic bacteriuria during the first postoperative month and poor prognosis for cadaver renal allografts merits further investigation.

Renal allograft fracture: clinicopathological study of 21 cases

Experience with renal allograft fracture occurring in 21 of 246 transplants performed over a 29-month period is reviewed. Clinical manifestations included pain and tenderness at the graft site, fever, and falling hematocrit. The fracture occurred without exception in the course of an acute rejection episode. Diagnosis was made from two days to seven weeks following transplantation; in 13 patients (62%) diagnosis was made within two weeks of surgery. Severe damage to the kidney necessitated nephrectomy in all but two transplants. Of those not removed at initial exploration only one regained function to permit a dialysis-free existance for several months. Histologic examination of the fractured kidneys revealed the pathogenesis to be acute rejection in 13 (62%), accelerated acute rejection in four (19%), and a combination of these processes in four (19%). Conclusions from this study are that fractures of renal allografts: (1) are more frequent than commonly realized; (2) are primarily due to the swelling of acute rejection; (3) are often characterized by sudden onset of pain in the region of the graft accompanied by fever and falling hematocrit; (4) should be treated by prompt surgical intervention to control hemorrhage, to perform nephrectomy if indicated, and to evacuate the hematoma in order to reduce the possibility of secondary infection.

Urinary infection in kidney transplantation

Urinary tract infection is the most frequent complication following renal transplantation and is important in the etiology of post-transplantation sepsis. The 87 renal homografts done in 1974 at The New York Hospital-Cornell Medical Center were reviewed retrospectively, with at least one year follow-up, in all cases, with particular attention to factors relating urinary tract infection to ultimate success or failure of the renal graft. The over-all incidence of urinary tract infection was 61%. Early infection was associated with a particularly poor prognosis for graft survival. Most patients with urinary infections after successful transplantation experience a combination of both early and late infections. Anatomic factors constitute a remediable cause of urinary infections after transplantation and should be searched for in cases of multiple, recurrent infections, de novo hypertension, or deterioration of previously stable graft function. There were significant differences in the bacteriologic spectrum of urinary tract infections associated with successful transplants as opposed to unsuccessful transplants.