Progressive renal insufficiency following cardiac transplantation: cyclosporine, lipids, and hypertension

The increasing success of cardiac transplantation has been attributed to the availability of potent immunosuppressive agents, including cyclosporine. With improved graft and patient survival, the incidence of chronic renal insufficiency has increased. We reviewed the medical records of patients who had undergone orthotopic cardiac transplantation and had been followed for at least 3 years posttransplantation to determine the risk factors at initial evaluation and in the early posttransplantation period for subsequent renal insufficiency. We followed 80 adult patients over a mean period of 4.7 years: 39 patients had a serum creatinine > or = 2.4 mg/dL at last follow-up (renal insufficiency or RI group); 41 patients had a serum creatinine < or = 1.7 mg/dL at last follow-up (controls). RI patients tended to be older and had a lower mean glomerular filtration rate (GFR) at initial evaluation. There were no differences in race, gender, or previous history of hypertension between the two groups. Although both groups experienced an improvement in GFR at transplantation and a subsequent decline in GFR by 6 months posttransplantation, the RI group achieved a lower peak GFR at transplantation and a far lower mean GFR at the 6-month analysis. Only the RI group showed a continued decline in GFR. The RI group had more severe hypertension and required a significantly greater number of antihypertensive medications. The RI group had a higher mean total cholesterol at 6 months, but this difference was not sustained. They also had higher triglyceride levels and lower high-density lipoprotein (HDL) levels; there was no difference in low-density lipoprotein (LDL) levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracic BB injuries in pediatric patients

Penetrating thoracic injury from BB shot remains an innocuous event in most patients, but factors including location, proximity, gun type, and patient weight may identify groups at risk. The following cases demonstrate morbidity and mortality in two patients, and this experience may suggest the need for reassessment of this injury.

Cyclosporine treatment of lupus membranous nephropathy

Few studies describe the treatment of membranous nephropathy associated with systemic lupus erythematosus. Although cyclosporine-A has been used to treat patients with the nephrotic syndrome and also with systemic lupus, only a few of these patients have had lupus membranous nephropathy. In this pilot study, we assessed the safety and efficacy of cyclosporine in ten nephrotic patients with either pure membranous lupus nephropathy (seven patients) or membranous lupus nephropathy with superimposed mild proliferative lesions (three patients). Cyclosporine (4-6 mg/kg/day) alone (2 patients), or in conjunction with low dose corticosteroids (8 patients) was given for a period of up to 43 months. Six patients achieved a nadir proteinuria of less than 1 gram daily, two patients decreased urinary protein excretion to 1-2 grams daily, and the remaining two patients continued to excrete over 2 grams of protein daily. All patients experienced symptomatic improvement of their nephrotic syndrome and serum creatinine was not significantly increased at the end of the study period. Three patients with superimposed mild proliferative lesions experienced renal and systemic lupus flares while on treatment requiring additional immunosuppressive therapy. Side-effects were minor except for transient rises in serum creatinine in one patient and a case of drug-related hepatitis possibly caused by cyclosporine. Repeat renal biopsies in five patients revealed a decrease in the lupus activity index and a rise in the chronicity index. There was an increase in the stage of the membranous nephropathy on these repeat biopsies, but a reduction in the number of fresh deposits.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous pulse cyclophosphamide treatment of severe lupus nephritis: a prospective five-year study

Despite its widespread use, there are only a few published studies of the use of intravenous high dose pulse cyclophosphamide in systemic lupus nephritis. There are few data about the long-term efficacy and safety of this form of therapy. This study evaluates the clinical efficacy, toxicity, and effects on renal morphology of this regimen in patients with severe lupus nephritis followed prospectively over a five-year period. Twenty consecutive patients with severe active lupus nephritis were enrolled in a treatment regimen of six monthly intravenous pulses of cyclophosphamide (0.5 to 1 g/m2) together with high dose corticosteroid therapy which was rapidly tapered. Efficacy was assessed by improvement or stabilization of clinical, serologic and renal functional parameters. Repeat renal biopsies were performed in 15 patients. Potential toxicity related to therapy was documented. Over the first six months of treatment, this regimen resulted in improvement of clinical activity, lupus serology, stabilization of renal function and decreased proteinuria in 19/20 patients. Nephrotic syndrome remitted in 8/10 patients by one year. Over five years of follow-up, there were five treatment failures defined as a doubling of serum creatinine over baseline. At five years, 3 patients required renal replacement therapy. Elevated plasma creatinine at time of first biopsy, degree of proteinuria, histologic activity and chronicity were not statistically correlated with treatment failure. Patients who failed to respond to this treatment were, however, more likely to have diffuse proliferative lupus nephritis (WHO Class IV) lesions on initial biopsy.(ABSTRACT TRUNCATED AT 250 WORDS)

Renal transplantation in anticardiolipin antibody-positive lupus erythematosus patients

Up to 44% of patients with systemic lupus erythematosus have antiphospholipid antibodies, which in some patients have been associated with thrombocytopenia, in vitro coagulation abnormalities, and a thrombotic tendency. Patients with lupus nephritis who reach end-stage renal disease may continue to have anticardiolipin antibodies (ACL-Ab) at the time of renal transplantation despite a lack of clinical or serologic activity of systemic lupus. The risk of thrombotic and other complications has not been previously reported in these patients. To evaluate the effect of ACL-Ab on the course of renal transplantation, the clinical course of eight ACL-Ab-positive lupus patients transplanted in the period from January 1990 to June 1992 were compared with five ACL-Ab-negative lupus patients transplanted during the same period. All patients had lupus nephritis as the cause of renal failure. There were four thrombotic episodes in the patients who were ACL-Ab-positive but none in the control group. Neither of the two groups differed in the number of rejection episodes, the rate of graft loss, or renal function at last follow-up. Patients with systemic lupus erythematosus who are ACL-Ab-positive can be successfully transplanted. However, these patients require attention to possible thrombotic events with a potential role for prophylactic anticoagulation.

The effect of prostaglandin E1 analog misoprostol on chronic cyclosporin nephrotoxicity

Cyclosporin A has markedly improved graft survival in transplant patients but its side effects, such as renal toxicity and hypertension, pose management problems in transplant recipients. This toxicity has been attributed to prostaglandin inhibition. Concurrent administration of misoprostol (a prostaglandin E1 analog) prevents chronic cyclosporin A-induced nephrotoxicity but not hypertension in rats.

The nephrotic syndrome, lipids, and risk factors for cardiovascular disease

The hyperlipidemia associated with the nephrotic syndrome is well characterized. There is, however, a paucity of data in humans on the risk factors for atherosclerotic heart disease and the role of hyperlipidemia on the risk of progression of renal disease in this population. In our study, we retrospectively evaluated a large uniform population of patients (mean creatinine, 1.78 mg/dL; mean 24-hour proteinuria, 7.1 g) with idiopathic nephrotic syndrome for the presence of risk factors for coronary artery disease. One hundred patients with either focal segmental glomerulosclerosis (n = 56) or membranous nephropathy (n = 44) were assessed for the following cardiovascular risk factors: male sex or postmenopausal female, hyperlipidemia, hypertension, smoking history, and left ventricular hypertrophy. Sixty-six percent of the patients were either male or postmenopausal females; 35% were smokers. Hypertension and left ventricular hypertrophy were present in 53% and 13% of patients, respectively. Eighty-seven percent, 53%, and 25% of patients had a total cholesterol of more than 200 mg/dL, more than 300 mg/dL, and more than 400 mg/dL, respectively. Low-density lipoprotein cholesterol was greater than 130 mg/dL and greater than 160 mg/dL in 77.2% and 64.9% of patients, respectively. Virtually all patients (99%) had at least one risk factor for cardiovascular disease; over two thirds (68%) had two risk factors and over one quarter (26%) had three risk factors. In comparing the group that progressed to renal failure with the groups that did not, the initial mean serum cholesterol was lower in the group that progressed (292 mg/dL v 388 mg/dL, P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The epidemiology of peritonitis in acute peritoneal dialysis: a comparison between open- and closed-drainage systems

We performed a prospective study to examine the epidemiology and microbiology of peritonitis complicating acute intermittent peritoneal dialysis (IPD) performed in an in-hospital setting for the management of acute and chronic renal failure and to see the effect of a closed-drainage system on altering the frequency and cause of peritonitis. Over a 15-month period, 79 patients were treated with acute IPD for a total of 136 treatments each ranging in length from 2 to 40 days (median, 4 days). The majority of cases had acute renal failure (ARF; 65%) and were treated in intensive care units (ICUs; 74%) with serious comorbid conditions (60%). About half were treated with a two-bag, ventable (open)-drainage system with unprotected spikes, and the other half were treated with a single-bag, spike-protected, closed-drainage system. There were 27 cases of peritonitis for a rate of 4.5 cases/100 patient-days at risk. About half were gram-positive infections; the remainder were gram-negative or mixed (25%) or Candida sp (25%). The use of a closed-drainage system reduced the incidence of system-related peritonitis from 3.6 to 1.5 cases/100 patient-days. There was a high rate of peritonitis in the first 48 hours of treatment, which fell to a low stable rate thereafter and remained so for up to 15 days of continuous IPD. The use of a closed-drainage system eliminated the early (< 48 hours) high rate of peritonitis and maintained a low constant rate of peritonitis throughout treatment. There was an association of ARF and severe comorbid disease with more virulent organisms (gram-negative, mixed, and Candida sp), which, in turn, were both associated with antecedent broad-spectrum antibiotic therapy. Random positive surveillance cultures showed a frequency distribution similar to that of peritonitis cases over the duration of treatment, but with less virulent organisms. Peritonitis in acute IPD occurs when large or repeated inocula of organisms from the prevailing flora overwhelm the peritoneal immune clearance mechanisms. Prolonged courses of broad-spectrum antibiotic therapy provide no protection, but shift the resulting infecting flora toward more virulent pathogens. A closed-drainage system provides one method to reduce the frequency of peritoneal contamination.

Postoperative apnea in infants

This is a review of 127 neonates evaluated for postoperative apnea and bradycardia (A&B) after inguinal surgery. The patients could be divided into three groups based on postconceptional age (PCA) at operation. Ten of 29 patients operated on at PCA of 33 to 39 weeks developed episodes of A&B. Preoperative assessment was not reliable in their identification. In the second group of 54 patients at PCA 40 to 44 weeks, 8 developed A&B, whereas in the third group of 44 patients at PCA of 45 to 60 weeks 1 patient developed A&B. In the latter two groups preoperative assessment identified all patients at high risk. We conclude that after PCA of 40 weeks patients at risk for A&B can be identified preoperatively. Patients operated on up to 39 weeks PCA should all be observed in the hospital.

Button gastrostomy obstructing the ileocecal valve removed by colonoscopic retrieval

A 16-year-old male with profound developmental disability acutely developed retching, irritability, and abdominal distension. He had undergone a fundoplication and placement of a feeding gastrostomy 6 months earlier. A button gastrostomy tube was subsequently placed, but was noted to be missing from the stoma when the patient was awakened by his mother one morning. Within 48 hours he developed signs of abdominal obstruction. Abdominal radiography confirmed the presence of the gastrostomy button at the ileocecal valve. After a trial of decompression and medical management failed, the button was successfully removed endoscopically, resulting in prompt resolution of the obstruction. Gastrostomy buttons are a newer alternative to conventional catheters, but can become dislodged and migrate, as illustrated by this case. Refinements in the outer wing design may be needed.

Colonic strictures following successful medical management of necrotizing enterocolitis: a prospective study evaluating early gastrointestinal contrast studies

This is a prospective study of 50 patients with neonatal necrotizing enterocolitis (NEC) treated successfully by medical means. They were all screened with an upper gastrointestinal (GI) contrast study after 14 days of healing and prior to establishment of feeding. Thirty-six patients (72%) with normal upper GI examinations responded well to a graduated increase in feeding. Another 5 (10%) with questionable areas on their upper GI examination had a normal follow-up contrast enema. Feeding was successfully established in this group of infants also. The remaining 9 patients (18%) had demonstrable strictures in both contrast studies. After elective resection of strictures with restoration of intestinal continuity, they were also fed successfully. No delayed strictures were seen in any of the patients. We propose that this method of evaluation is safe, efficient and reliable in the diagnosis of strictures that develop in patients recovering from NEC.

Granulocytic sarcoma of the ileum treated by bone marrow transplantation

An 8-year-old boy with a granulocytic sarcoma of the proximal ileum metastatic to mesenteric lymph nodes was placed into complete remission with surgical excision of the primary tumor and conventional induction chemotherapy with daunorubicin and cytosine arabinoside. He was then treated with high dose cytosine arabinoside, fractionated total body irradiation, and allogeneic marrow transplantation from his 22-month-old brother who was completely matched at the major histocompatibility complex. Methotrexate was given following the transplant to prevent graft-versus-host disease (GVHD). His post-transplantation course was complicated by a transient autoimmune hemolytic anemia related to an ABO blood group incompatibility and hepatic fungal microabscesses which responded to Amphotericin therapy. Four years following the transplant the patient remains in complete remission. The prognosis for patients with granulocytic sarcoma has been poor although, perhaps, improved over the past decade. This is the first published case report of successful treatment of a granulocytic sarcoma of the ileum by allogeneic marrow transplantation.

Perianal abscess and fistula-in-ano in children

The authors present a retrospective review of 40 pediatric patients with perianal abscess and/or fistula-in-ano. The total patient population could be divided clinically into 2 broad groups. The first group consisted of 22 infants younger than 2 years of age, all of whom were males, and 10 of whom presented with recurrences after previous incision and drainage. Of the 14 infants presenting with an abscess, in 12 (85.7 percent), a fistula-in-ano was discovered at surgery. In contrast, in the group of 18 children older than 2 years of age, there were 7 females and 11 males, and fistulas were identified in only 7 of 13 patients (54.8 percent) who presented with abscesses. Surgical treatment consisted of examination under anesthesia and a diligent search for a fistulous tract. Abscesses were primarily saucerized and fistulotomy and cryptotomy of the confluent crypt was performed if a fistulous tract was identified. The only recurrences with this form of treatment occurred in the two immunocompromised patients.

Obstructive uropathy in the newborn

The three common causes of urinary obstruction in the newborn are ureteropelvic obstruction, posterior urethral valves, and ureteroceles. Considerable controversy exists regarding their embryology and treatment, yet the basic principles are clear and consist of relief of urinary obstruction, prevention of infection, and maintenance of renal function. Subsequently, total reconstruction can be implemented.

Lipogenic activity and brown fat content of human perirenal adipose tissue

The incorporation of 3H2O and/or 14C-glycerol into lipids and the specific activities of the enzymes acetyl CoA carboxylase and lipoprotein lipase were measured in the perirenal and subcutaneous adipose tissue of human subjects. The perirenal adipose tissue of younger subjects with higher brown adipocyte content had higher rates of lipogenesis and enzyme activities per gram tissue than the corresponding subcutaneous tissue. However, in individual specimens, the perirenal/subcutaneous ratios of all but one of the above parameters failed to show a correlation with the brown adipocyte content of the perirenal adipose tissue. One parameter, namely 3H2O incorporation into fatty acids per adipocyte, did relate to the brown adipocyte content of the perirenal adipose tissue in four normal-weight patients only.

Colon interposition vaginoplasty: a modification of the Wagner-Baldwin technique

A technique for vaginal reconstruction using a segment of colon, with particular emphasis on the perineal anastomosis.

Computed tomography in the assessment of pediatric abdominal trauma

A retrospective review was conducted to determine the clinical reliability of computed tomography(ic) (CT) in the initial evaluation of pediatric blunt abdominal trauma. Sixty patients underwent CT with infusion over the two-year study period. Seventeen injuries were identified by CT scans in 12 patients. Injuries included splenic hematoma, hepatic injury, duodenal hematoma, traumatic pancreatitis, retroperitoneal hematoma, renal pelvis laceration, and perinephric hematoma. Three patients required abdominal exploration and CT findings were confirmed in these cases. Other diagnostic studies (nuclear imaging, ultrasonography, upper gastrointestinal tract studies) that were obtained in some patients also confirmed the CT findings. Patients who had normal CT scans had unremarkable hospital courses, and none required reevaluation for missed injury. Only two CT scans were inadequate due to motion artifact.

Overflow urinary incontinence due to carbamazepine

We describe the first well documented case of overflow urinary incontinence owing to prolonged carbamazepine treatment for temporal lobe seizures. Carbamazepine increased the bladder capacity to 1,700 ml. and was accompanied by symptoms of urgency and frequency. After carbamazepine was discontinued and the patient was given primidone the voiding symptoms disappeared. Post-voiding catheterization of the bladder showed minimal residual urine volume. In a review of urological adverse reactions of anticonvulsant drugs that are effective in the management of temporal lobe seizures we found that only primidone and phenobarbital have not been convincingly associated with such side effects. However, phenytoin and clonazepam have been linked with urinary incontinence, and valproic acid with enuresis.

Penoplasty for buried penis secondary to "radical" circumcision

An unusual complication of neonatal circumcision occurs when skin from the penile shaft is excised along with the prepuce. Upon healing of the wound, the penis gets buried in the scrotum. Repair is complicated by the lack of available skin to cover the shaft of the penis. We describe a surgical technique for correction of this condition.