Alpha-human-ANP response to preanesthetic volume expansion and subsequent renal transplantation in diabetic and nondiabetic uremic patients

alpha-Human atrial natriuretic peptide (ANP) concentrations were measured in 11 diabetic patients with uremia and in 16 nondiabetic uremic controls undergoing renal transplantation after preanesthetic volume expansion with 1000 ml saline solution within 10 min. Two diabetic and seven nondiabetic patients received grafts from living donors and the rest from cadaveric donors. Volume expansion induced a significant increase in the cardiac filling pressures (P less than 0.001), which were kept at that level especially at declamping, which was preceded by mannitol infusion. The baseline mixed venous ANP levels were significantly higher in the diabetic (252 +/- 6 pg/ml) than in the nondiabetic group (103 +/- 14 pg/ml; P less than 0.05). In the nondiabetic group, ANP increased to 177 +/- 40 pg/ml as a response to volume loading (P less than 0.05); it was not clearly changed in the diabetic group. Arterial ANP increased from 267 +/- 55 to 343 +/- 75 pg/ml in the diabetic group (P less than 0.05 and from 102 +/- 17 to 147 +/- 31 pg/ml in the nondiabetic group (P less than 0.05). During transplantation, mixed venous ANP decreased to 125 +/- 55 pg/ml in the diabetic and to 80 +/- 10 pg/ml in the nondiabetic group (P less than 0.001). About 30% of circulating ANP was taken up by the transplant irrespective of postoperative graft function. Two patients in each group showed delayed diuresis requiring postoperative dialysis therapy (22% of all cadaveric transplantations). ANP levels at declamping had no correlation to the outcome of kidney function.

Acute rejection in kidney grafts with delayed onset of graft function. A duplex-Doppler study

Forty-five kidney transplant recipients with delayed onset of diuresis due to acute tubular necrosis (ATN) were examined with duplex ultrasonography (DU). Resistive index (RI) was measured on the 4th post-transplant day. Eleven grafts (24%) developed acute rejection. Mean RI prior to rejection of the 4th postoperative day in these grafts was 0.97 and in the 34 grafts which did not develop rejection mean RI was 0.82. There were 2/26 rejections (8%) in the group of grafts with an initial RI below 0.9 and 9/19 rejections (47%) in the group of grafts with RI of 0.9 or above on the 4th post-transplant day. Six months postoperatively there were 2/26 nonfunctioning grafts in the group with lower initial RI values (less than 0.9) and 6/19 nonfunctioning grafts in the group with higher indices (greater than or equal to 0.9). In nonfunctioning grafts a high initial RI (greater than or equal to 0.9) indicates that these grafts will be prone to developing acute rejection.

Induction of HLA class II antigen and interleukin 2 receptor expression in acute vascular rejection of human kidney allografts

The induction of HLA class II antigens on graft tubular cells and IL-2 receptor expression on the infiltrating lymphoid cells was studied in 245 prospective aspiration biopsies taken during the first posttransplant month from 20 human renal allografts with histologically verified acute vascular rejection (AVR). Based on the histological findings, the specimens were categorized into two main groups: biopsies from grafts with features of AVR only, and biopsies with a combination of AVR and acute cellular rejection (ACR). Also in the second group the AVR findings were predominant. Biopsies were further divided into two subgroups, depending on whether the rejection was reversible or irreversible. Evaluation of class II and IL-2R expression was done by indirect immunoperoxidase staining using monoclonal antibodies. The initial posttransplant tubular cell class II expression was low in all 20 grafts, with 5-15% positive tubular cells, and IL-2R expression was negative. All 13 grafts with a combination of AVR and ACR displayed class II induction, closely correlating to the blast response, with 50% positive tubular cells on days 2-7 after the onset of rejection, and declining thereafter back to prerejection level in grafts with reversible rejection. In grafts with irreversible rejection, tubular cell class II expression remained elevated. A similar pattern was observed with regard to IL-2R expression: the IL-2R positive cells disappeared from the grafts with reversible rejection, but they persisted in the irreversible rejections. The same pattern of class II and IL-2R expression was observed in grafts with pure AVR and reversible rejection. Instead, completely different findings were seen in grafts with pure AVR and irreversible rejection: there was neither class II induction on tubular cells nor IL-2R expression on lymphoid cells. The persistant inflammation was dominated by mononuclear phagocytes, and no blast response could be detected during the entire follow-up. These findings demonstrate a close relationship between IL-2R expression and tubular cell class II induction also in AVR, in the majority of cases. On the other hand, the findings in grafts with pure AVR in histology and irreversible rejection suggest that AVR is a heterogenous group of rejections, where different cellular and molecular mechanisms are operating.

Pharmacokinetics of propofol and haemodynamic changes during induction of anaesthesia in uraemic patients

The pharmacokinetics of an i.v. bolus of propofol 2 mg kg-1 were studied in 10 uraemic patients undergoing renal transplantation and in seven healthy controls matched for age, weight and duration of anaesthesia. Haemodynamic changes during induction of anaesthesia were recorded in the uraemic and in 10 healthy control patients. Pharmacokinetic variables were similar in uraemic and control patients; mean elimination half-lives were 1638 (SD 340) min and 1714 (842) min, respectively. Induction of anaesthesia with propofol was preceded by fentanyl 3 micrograms kg-1. After administration of propofol over 60 s, systolic arterial pressure decreased by 19 (12)%, and by 24 (11)% in the adequately volume loaded uraemic and healthy patients, respectively. Propofol caused a marked peripheral vasodilatation in all patients. A moderate increase in systolic arterial pressure after intubation was statistically significant only in the control patients (P less than 0.01). We conclude that, in terms of pharmacokinetics and haemodynamic changes, propofol may be used safely for the induction of general anaesthesia in uraemic patients.

Leishmaniasis diagnosed from bronchoalveolar lavage

A 51-year-old renal transplant patient, whose spleen had been removed 11 years ago, was admitted to hospital for elective surgery, which was cancelled as she developed spiking fever and nonproductive cough and her general condition deteriorated. After 2 weeks, leishmaniasis was unexpectedly diagnosed from a bronchoalveolar lavage specimen, which had been subjected to parasitological examination under the suspicion of pneumocystosis. Isoenzyme typing identified the parasite as Leishmania infantum. The patient had visited Malaga, Spain, twice a year, the last trip taking place 1 month before admission. Specific treatment was followed by rapid recovery without relapse during 1.5 years. Splenectomy and immunosuppressive medication obscured the clinical suspicion of leishmaniasis. The case is a reminder of the interstitial pneumonitis in leishmaniasis and emphasizes the value of broad-spectrum methods detecting a variety of parasites.

Cholestasis and kidney dysfunction in liver transplant patients reduces cyclosporine metabolite excretion

Cyclosporin A (CsA) is metabolized principally by the hepatic cytochrome P 450-dependent microsomal enzyme system and eliminated virtually entirely as metabolites, mainly in the bile. Only less than 1% of the oral dose is excreted unmetabolized in the urine or bile. Metabolites account for 50-70% of the total CsA in whole blood. Some of the metabolites have been shown to possess an immunosuppressive and even toxic effect but the role of this effect remains uncertain. In order to evaluate the effect of liver and kidney failure on the metabolism of CsA, we studied twelve patients who had undergone liver transplantation. The samples were collected during the first 4 postoperative weeks. The aim of the study was threefold: to evaluate (1) whether an impairment of liver function, as measured by standard biochemical liver function tests, decreased the metabolism or excretion of CsA; (2) whether an induction of either the CsA metabolites or the parent compound took place in the first postoperative period; and (3) whether kidney failure, as measured by serum creatinine, correlated with blood levels of CsA or its metabolites.

Expression of activation markers, HLA class II and IL-2R in acute vascular rejection of human renal allografts

We analyzed the expression of class II antigens on graft tubular cells and the expression of IL-2R on lymphoid cells in 314 prospective aspiration biopsies taken from 30 consecutive patients with histologically verified acute vascular rejection (AVR). Based on histology, two main groups were seen: 11 grafts had features of AVR only and 19 grafts had a combination of AVR and acute cellular rejection (ACR). The AVR findings were also predominant in the latter group. In the grafts with a combination of AVR and ACR, patterns similar to ordinary ACR were seen in class II and IL-2R expression. On the contrary, no class II or IL-2R induction could be seen in the grafts with pure AVR and irreversible rejection. This pattern, demonstrated by immunocytology, suggested that AVR is a heterogenous group of rejections, where different cellular and molecular mechanisms are operating. Humoral mechanisms might be involved in these rejections.

Strenuous physical activity, aspirin and heat stress increase urinary dolichols: evidence for lysosomal origin of urinary dolichols

Strenuous physical activity, aspirin and heat stress (Finnish sauna) were all found to significantly increase urinary dolichol excretion. In contrast, serum dolichol concentration studied before and after aspirin and sauna, was not affected. A similar aspirin-induced increase, as seen in urinary dolichol concentration, was also observed in the urinary excretion of two lysosomal enzymes--beta-hexosaminidase and beta-glucuronidase. In contrast, the excretion of two non-lysosomal enzymes--lactate dehydrogenase and leucine aminopeptidase--was not affected. The lack of correlation between serum and urinary dolichols, and the parallel increase in urinary dolichols and the activities of the lysosomal enzymes suggest that urinary dolichols may be derived from the lysosomes of the renal cells. We conclude that the finding of increased urinary dolichol concentrations in some relatively common conditions limits the clinical use of urinary dolichols as a diagnostic tool in neuronal ceroid lipofuscinosis or alcoholism.

Serum dolichols in different clinical conditions

We studied the effect of seven different clinical diseases (viral infections, bacterial infections, malignant diseases, cardiovascular diseases, gastroenterological diseases, endocrinological diseases, and rheumatic diseases) as well as normal pregnancy on serum dolichol concentrations in 76 hospitalized patients and in 10 pregnant women. In contrast to urinary dolichols, serum dolichols were not significantly increased in any of these conditions, suggesting that dolichol levels in serum and urine are independently regulated. Furthermore, we found that serum dolichol concentration does not undergo diurnal variation, as in healthy volunteers time of blood sampling did not affect serum dolichols. Our results suggest that serum dolichol concentration, which has earlier been found to be exceptionally high in aspartylglucosaminuria and mannosidosis, might serve as a laboratory marker for these recessively inherited lysosomal storage diseases.