A Controlled Sequential Evaluation of Open Donor Nephrectomy Versus Classical and Modified Laparoscopic Donor Nephrectomy: An Update

This study sought to determine the procedure of choice for kidney retrieval for transplantation by comparing open donor nephrectomy to laparoscopic donor nephrectomy and modified laparoscopic donor nephrectomy and by analyzing intraoperative donor and recipient graft function parameters. In this single-center, controlled, sequential analysis, 100 consecutive donor-recipient pairs were recruited, grouped according to surgical procedure, and operated upon between 1997 to 2004, as follows: group 1, open donor nephrectomy (n = 30), performed from 1997 to 2000; group 2, laparoscopic donor nephrectomy (n = 28), performed from 2000 to 2002; and group 3, modified laparoscopic donor nephrectomy (n = 42), performed from 2002 to 2004. Data were analyzed by type of operative procedure, graft function, length of hospital stay, and donor recovery time. Operative time was similar for all three surgical approaches. Warm ischemia times for open donor nephrectomy and modified laparoscopic donor nephrectomy were similar. Acute tubular necrosis occurred in 7% of patients in all groups. Donor recovery and lengths of hospital stay were significantly shorter for laparoscopic approaches. Donor complications were similar in numbers, differing only in complication type. Graft function and survival were similar for all three surgical approaches. We conclude that modified laparoscopic donor nephrectomy is the procedure of choice for living kidney retrieval.

Observations on Quadruple Immunosuppression Maintenance Therapy Using Rapamycin, Low-Dose Cyclosporine, Mycophenolate Mofetil, and Prednisone Following ATG Induction

INTRODUCTION

We prospectively evaluated an immunosuppressive regimen consisting of rapamycin (Rapa), low-dose cyclosporine (CsA), low-dose mycophenolate mofetil (MMF), and prednisone (group 1) versus a regimen of CsA, MMF, and prednisone (group 2) in mismatched living related donor (LRD) and living unrelated donor (LUD) kidney transplantation.

METHODS

Group 1 included 24 transplant recipients of eight mismatched LRD and 16 LUD, treated with Rapa, low-dose MMF, CsA, and prednisone. Group 2 included 53 transplant recipients (25 LRD, 27 LUD, and one cadaveric donor), treated with MMF, CsA, and prednisone. All patients in group 1 received a single bolus of rabbit-anti-human T-lymphocyte immune serum (ATG-Fresenius 4 to 6 mg/kg). In group 2, patients received either a single ATG or an extended ATG course (3 to 5 days postoperatively).

RESULTS

Acute rejection occurred in one patient in group 1 (4.2%) and in five patients (9.4%) in group 2, all of which resulted in graft loss. Serum creatinine was not significantly different between the two groups.

CONCLUSION

The immunosuppressive protocol of Rapa, CsA, MMF, and prednisone with single-bolus induction ATG achieves excellent immunosuppression and graft survival with no apparent risks in the short and intermediate term.

A Controlled Sequential Evaluation of Laparoscopic Donor Nephrectomy Versus Open Donor Nephrectomy: An Update

INTRODUCTION

In this study, we compared laparoscopic (lap Nx) to open donor nephrectomy (open Nx) with specific emphasis on outcomes in the donor and recipient.

METHODS

This single-center sequential analysis recruited 100 consecutive donor-recipient pairs operated on from 1997 until 2003. The open Nx (n = 30), were performed between 1997 and 2000; the lap Nx (n = 70) were performed between 2000 and 2003. Prospective records included operative data, anatomic details of the graft, hospital stay, and donor recovery.

RESULTS

Donor characteristics and renal function were similar for open Nx and lap Nx. Operative parameters were similar except for the longer warm ischemia time in lap Nx versus open Nx (3.14 +/- 2.10 vs 1.5 +/- 0.5 minute, P < .001). Donor complications were equivalent in number, but differed in spectrum with a trend toward more intraoperative complications with lap Nx versus more postoperative complications for open Nx. Donor recovery, hospital stay, and return to work were improved in lap Nx versus open Nx (P < .001). Renal function of grafts after lap Nx were similar to open Nx: 2-year serum creatinine values of 1.26 +/- 0.21 versus 1.31 +/- 0.40, respectively. Graft survivals were similar.

CONCLUSION

Compared to open Nx lap Nx offers major advantages to the donor, and yields similarly favorable results in graft outcomes. However, it is more surgically demanding. Consequently, lap Nx should be adopted as the procedure of choice for living kidney retrieval.

Technical Modifications of Laparoscopic Donor Nephrectomy: Improved Results With Refinements in Technique That Mimic Open Nephrectomy

INTRODUCTION

We have performed laparoscopic donor nephrectomy (lap Nx) since 2000. In June 2002, we modified the technique to minimize the known disadvantages of ATN and delayed graft function. We review our series of lap Nx before and after introduction of these modifications, respectively.

METHODS

Four technical modifications of lap Nx were introduced following the initial previously described 28 cases (Group I) and applied to the consecutive 42 cases described herein (Group II): (1) decreasing the intra-abdominal pressure from 15 mm Hg to 8 mm Hg; (2) early dissection of the ureter and gonadal vein followed by vascular dissection (sharp and blunt using hydrodissection); (3) leaving the left gonadal vein in continuity with the left renal vein; and (4) early introduction of the Endocatch bag.

RESULTS

Operative time was 276.6 +/- 67.1 min vs 210.0 +/- 38.0 min for groups I and II, respectively (P = .04). Warm ischemia was 4.9 +/- 1.9 min vs 1.5 +/- 0.9, min for groups I and II, respectively (P < .01). ATN occurred in 3/28 (10.7%) in group I vs 2/42 (4.8%) in-group II. There was one-vascular insult in the initial 5 Rt lap Nx, namely, transection of a segmental artery, that was reconstructed by bench repair without an impact on the outcome. Conversion was needed in 3/28 (10.7%) group I, but none of group II donors.

CONCLUSION

The outcome of lap Nx can be significantly improved by applying technical modifications that simulate open Nx.

Leiomyoma of the urethra: report of 3 cases of a rare entity

Leiomyomas are benign tumors of smooth muscle origin that can occur at any location in the urinary tract. Although rare, they are the most common mesenchymal neoplasms of the urethra. They are more frequent in females than in males. Only 3 cases of leiomyomas of the male urethra and multiple cases in the female have been reported in the English-language literature. We report 2 additional cases of leiomyoma of the male urethra and 1 more case of the female urethra and describe their differential diagnoses and management.

A guideline to clinical utility of prostate specific antigen

Prostate cancer has emerged as the most common tumor effecting adult men. In the USA, 300,000 cases each year, and some 40,000 deaths per year are expected from this disease. Once prostate cancer gets to an advanced stage, one cannot prevent its progression and cure is no longer possible. Thus, to effect the course of prostate cancer and to diminish the death rate from this disease, it should be detected at its early stages. The prostate specific antigen serum test is the best tumor marker present but it is certainly not perfect. The proper utility of prostate specific antigen testing, and analysis of prostate specific antigen parameters, will allow us to detect prostate cancer at earlier stages, and prevent progression and death rates from this disease. In this manuscript, we review the current status of prostate specific antigen testing for early detection and staging of prostate cancer, as well as its role for monitoring response to various forms of therapy.

The value of free and total prostate specific antigen in identifying patients for prostatic biopsy and its relationship to Gleason score and number of positive cores

INTRODUCTION AND OBJECTIVES

The percentage of free over total prostate specific antigen (%F/T PSA) seems to enhance the predictive value of PSA in diagnosing prostate cancer. We evaluated the value of F/T PSA in 50 consecutive patients who underwent prostate needle biopsy, its relationship to the Gleason score and number of positive cores.

MATERIAL AND METHODS

50 patients underwent prostate needle biopsy for abnormal PSA and/or abnormal digital rectal examination (DRE). There were 8 patients with PSA equal or less than 4 ng/ml, 6 with F/T PSA < 20%, group I (GI). 27 patients with PSA between 4.1 ng/ml and 10.0 ng/ml, 20 with F/T PSA < 20%, group II (GII) and 15 patients with PSA > 10.1 ng/ml (13 with F/T PSA < 20%), group III (GIII). At least six needle biopsies were obtained guided by transrectal ultrasound selectively or randomly. Pathological evaluation included Gleason grade and number of cores involved.

RESULTS

21/50 patients (42%) had positive biopsies, 3/8 in GI, 8/27 in GII (6 had negative DRE) and 10/15 in GIII (9 had positive DRE). 19/21 patients with positive biopsies had F/T PSA < 20%. The sensitivity, specificity and positive predictive value of PSA between 4-10 ng/ml and F/T PSA < 20% was 87.5%, 31% and 35% respectively. Stratifying patients with positive biopsies to F/T PSA < 10%, F/T PSA > 10% and the three PSA groups, there was no relationship to either Gleason score or number of positive cores.

CONCLUSION

With a cutoff of 20%, F/T PSA seems to be an important parameter in selecting patients with abnormal PSA for biopsy. It will be helpful mostly with PSA 4-10 ng/ml. No relationship was observed between the level of F/T PSA, grade or number of positive cores.

Use of small and large bowel in renal transplantation

The continued success of renal transplantation has provided a higher quality of life for properly selected patients with ESRD. It is also a much more cost-effective and efficient treatment of ESRD compared with chronic dialysis. Innovative urologic reconstructive surgery using enteric segments for both continent and incontinent urinary diversions has permitted this therapeutic modality to be offered to the recipient with lower urinary tract disease not previously amenable to renal transplantation. These same reconstructive techniques using ileal segments have also permitted preservation of renal allografts with previously nonreconstructable renal pelvic or ureteral disease.

Kidney transplantation in highly sensitized patients: reappraisal of etiology, evaluation, and management protocols

Transplant recipient sensitization to major histocompatibility complex (MHC) antigens is a major problem in clinical organ transplantation in terms of both magnitude and implication. Highly sensitized patients (HSPs) waiting for renal transplantation constitute a high-risk group with difficult management problems. In this review the factors involved in sensitization, detection of sensitization in the pretransplant period, various strategies tried in its prevention, and the current therapeutic approach to management of HSPs are discussed. Although prevention of sensitization is ideal, in practice a certain percentage of transplant recipients continue to exhibit hypersensitization despite all measures. Methods to remove preformed antibodies are effective but are expensive and not freely available. Aggressive immunosuppression based on cyclosporine (CsA) induction protocols constitute the mainstay in the management of HSPs. The availability of newer, potent, and more specific immunosuppressive agents, particularly those suppressing antibody synthesis, has opened a new avenue for more specific immunosuppression and better graft and patient survival following transplantation. Their clinical utility in improving patient and graft survival in HSPs needs to be evaluated.

Successful transplantation of a kidney with early membranous nephropathy

This report describes a patient with end-stage renal disease secondary to long-standing type II diabetes mellitus who received a cadaveric renal transplant from a 37-year-old woman who died of massive cerebral infarction. An autopsy performed on the donor following organ procurement revealed no obvious contraindications to transplantation. A renal biopsy of the donor kidney performed at the time of transplantation, however, subsequently showed early membranous nephropathy by electron microscopy. There was immediate graft function and the recipient continues to have good renal function 3 years post-transplantation.

Triple therapy in cadaveric renal transplantation: role of induction cyclosporine and targeted levels to avoid rejection

The updated data on 61 consecutive cadaveric transplants performed at our institution from 1987 to 1990 (followup 31 to 82 months, median 54 months) were analyzed with emphasis on cyclosporine monitoring and long-term results. All patients received triple therapy with cyclosporine induction, azathioprine and prednisone regardless of graft function, and they were preferentially placed on the calcium blocker nifedipine. We monitored 12-hour cyclosporine trough levels in whole blood using high performance liquid chromatography and the dose was adjusted to maintain levels at 150 ng./ml. or greater for the first 3 months. In 17 of 61 patients (28%) 22 rejection episodes occurred and 20 nephrotoxicity episodes occurred in 17 of 61 patients (28%). There was no significant difference in the mean cyclosporine levels among 32 rejection, nonrejection, nephrotoxic and nonnephrotoxic cases at any interval. Rejection occurred by 1 month in 13 (76%) and by 3 months in 15 (88%) of 17 patients. Comparisons were made in the first month to define the desirable cyclosporine levels by calculating the mean cyclosporine only within 10 to 14 days of rejection or nephrotoxicity events. The mean cyclosporine level before rejection was significantly lower than that for nephrotoxicity (188 +/- 113 versus 304 +/- 62 ng./ml., p < 0.01). The median cyclosporine level for first month rejection was also significantly lower than that for nonrejection (156 versus 218 ng./ml., p < 0.05) and it was significantly greater for nephrotoxicity versus nonnephrotoxicity (272 versus 218 ng./ml., p < 0.05). Of 13 rejections in the first month 10 (77%) were associated with mean levels of less than 210 ng./ml. Actuarial graft survival at 1, 3 and 5 years was 93.4%, 87.8% and 78.5%, respectively. The 3-year graft survival was significantly worse for patients who experienced acute rejection episodes versus those who did not (68.8% versus 96.7%, p < 0.05) but it was not different for nephrotoxic versus nonnephrotoxic groups (85.6% versus 79.6%). Long-term function was not influenced by the occurrence of acute nephrotoxicity events. These findings confirm the efficacy of triple therapy with induction cyclosporine in cadaveric transplantation, yielding improved short-term and intermediate graft survival without any adverse effects on long-term graft function. Specific cyclosporine level monitoring is invaluable, particularly initially, with high target levels of 200 ng./ml. or greater. The use of calcium blockers may have allowed higher cyclosporine dosing in the first 3 months, mitigating against cyclosporine associated chronic nephrotoxicity.

Defining the role of renal angiography in the diagnosis of renal artery disease

The current goal of angiography in the diagnosis of renal artery disease is poorly defined, probably because of the diversity of patients presenting for management. The current application of angiography is better understood when put into perspective with the patient population that we are trying to screen. There are two distinct patient populations with renovascular disease: those with uncontrolled hypertension and those with azotemia or risk of progression to end-stage renal disease. The role of angiography in these two patient populations is quite different. In patients with hypertensive renovascular disease, angiography should be applied rather late and should be preceded by other noninvasive testing to screen patients from those with essential hypertension, since the prevalence of this disease is low and the cost implications of applying angiography primarily are immense. The two promising tests in this setting are captropril renography and duplex ultrasound scanning. In contradistinction, patients with azotemic renovascular disease, suffering from bilateral renal artery stenoses, or suffering from stenosis of the renal artery in a solitary kidney may be better studied by early application of renal angiography, especially those at risk of progression and for whom intervention is indicated.

Genitourinary malignancies in organ transplant recipients

The current recommendations for management of patients with pre-existing neoplasms before transplantation is a function of the cure rate achieved with the available therapeutic modalities and the risk of recurrence following initiation of immunosuppression. Recurrences after transplantation, as well as de novo malignancies, although unpredictable in many cases, have been identified as arising in certain individuals at risk and are a result of multifactorial etiologies. These etiologies include oncogenic effects of immunosuppressive agents or their broken-down metabolites, depressed immunity, dampened immune response, and activation of oncogenic viruses (herpes group, EBV), carcinogens, congenital predilection, and dormant residual cancers of high malignant potentials. Better understanding of the interplay of these factors and longer follow-up of transplant recipients receiving contemporary immunosuppressive agents are needed in order to diminish the likelihood of tumor recurrence/development in this population. Judicious application of current information obtained from the transplant registries, better understanding of immunosuppressive agents and their long-term oncogenic effects, and careful and conscientious allocation of cadaveric organs are advised.

Simultaneous quadruple immunosuppression with cyclosporine induction therapy in high risk renal transplant recipients

High risk renal transplant recipients experience excess graft loss despite overall improvements in the results of cadaveric renal transplantation. We evaluated a novel immunosuppression regimen consisting of simultaneous administration of OKT3, cyclosporine, azathioprine and prednisone. Of the 12 high risk patients studied 5 received 2 transplants, 1 received 3 transplants and 8 had peak panel reactive antibodies of greater than 60%. The protocol consisted of cyclosporine (7 mg./kg. orally or 3 mg./kg. intravenously per day) starting from the day of transplant regardless of graft function; 5 mg. OKT3 per day for 10 to 14 days starting intraoperatively; 5 mg./kg. azathioprine per day for 2 days, then 1.5 mg./kg. per day and adjusted according to white blood cell counts, and prednisone taper at 2 to 0.4 mg./kg. per day on day 10. The dose of cyclosporine was increased to 14 mg./kg. per day orally when serum creatinine was less than 3 mg./dl. The cyclosporine whole blood levels (measured by high performance liquid chromatography) were maintained between 250 and 400 ng./ml. in the first 3 months. Followup evaluations ranged from 3 to 28 months (median 8.5). Seven patients (58.3%) had acute tubular necrosis and required dialysis support for 2 to 5 weeks. Six patients (including 5 with acute tubular necrosis) experienced 1 episode of acute rejection in the first 3 months (2 of these were due to accelerated vascular rejection). Two rejections responded to pulse steroid treatment, while 4 (including 2 with vascular rejection) were treated with antilymphoblast globulin rescue therapy for 10 to 14 days. Symptomatic cytomegalovirus pneumonia occurred in 3 patients (25%). There were no deaths or graft losses. No case of malignancy was observed to date. The serum creatinine is less than 2 mg./dl. in 9 patients, and 2.5 to 2.9 mg./dl. in the remaining 3. We conclude that simultaneous quadruple immunosuppressive regimen that includes induction cyclosporine and OKT3 is a highly effective therapy for high risk patients, yielding excellent short-term and intermediate success rates. Long-term results of this regimen, including neoplastic potentiation, cannot be addressed because of the limited followup of these patients.

Surgical aspects of renal transplantation: new approaches

Refinements in surgical techniques and newer approaches to renal transplantation have yielded a safe and consistent operation that can be applied to most patients with end-stage renal disease. It is important that the transplant surgeon is familiar with the variety of approaches, especially when dealing with high-risk recipients due to prior transplantation of aortoiliac atherosclerotic disease. This article reviews the different technical approaches for renal transplantation and the recent advances in the management of postoperative complications.

Posttransplant lymphocele presenting as 'acute abdomen'

Lymphoceles occurring after renal transplantation are frequently asymptomatic and are usually identified on routine ultrasonography of the allograft. A small percentage of them may increase in size and manifest due to their compression effects on adjacent structures or as lymphocutaneous fistula. An infected lymphocele would, in addition, give rise to local and systemic features. A case of infected lymphocele occurring 4.5 months after cadaveric renal transplant is reported. The patient presented in septicemia and features of generalized peritonitis. Emergency diagnostic laparoscopy revealed fluid collection in the peritoneal cavity. However, on exploratory laparotomy no intra-abdominal pathology was detected. Further evaluation revealed a large perigraft lymph collection which was drained percutaneously. Fluid and blood cultures grew Staphylococcus aureus. The patient recovered completely following external drainage and antibiotic administration.

Missile injury of upper ureter treated by delayed renal autotransplantation and ureteropyelostomy

We report a case of extensive upper ureteral loss due to a missile injury managed by delayed renal autotransplantation and ureteropyelostomy using the residual lower ureteral segment. The successful outcome attests to the value of this therapeutic strategy in severe traumatic injuries to the ureter secondary to bullet or shrapnel fragments.

Post-transplant lymphoceles: a critical look into the risk factors, pathophysiology and management

To define better the prevalence and pathophysiology of lymphoceles following renal transplantation, we prospectively evaluated 118 consecutive renal transplants performed in 115 patients (96 cadaveric, 22 living-related, 7 secondary and 111 primary). Ultrasonography was performed post-operatively and during rehospitalizations or whenever complications occurred. Perirenal fluid collections were identified in 43 patients (36%). Lymphoceles with a diameter of 5 cm. or greater were identified in 26 of 118 cases (22%). Eight patients (6.8%) had symptomatic lymphoceles requiring therapy. The interval for development of symptomatic lymphoceles was 1 week to 3.7 years (median 10 months). Risk factors for the development of lymphoceles were examined by univariate and multivariate analysis, and included patient age, sex, source of transplants (cadaver versus living-related donor), retransplantation, tissue match (HLA-B/DR), type of preservation, arterial anastomosis, occurrence of acute tubular necrosis-delayed graft function, occurrence of rejection, and use of high dose corticosteroids. Univariate analysis showed a significant risk for the development of lymphoceles in transplants with acute tubular necrosis-delayed graft function (odds ratio 4.5, p = 0.004), rejection (odds ratio 25.1 p < 0.001) and high dose steroids (odds ratio 16.4, p < 0.001). When applying multivariate analyses using stepwise logistic regression, only rejection was associated with a significant risk for lymphoceles (symptomatic lymphoceles--odds ratio 25.08, p = 0.0003, all lymphoceles--odds ratio 75.24, p < 0.0001). When adjusting for rejection, no other risk factor came close to being significant (least p = 0.4). Therapy included laparoscopic peritoneal marsupialization and drainage in 1 patient, incisional peritoneal drainage in 4 and percutaneous external drainage in 3 (infected). All symptomatic lymphoceles were successfully treated without sequelae to grafts or patients. We conclude that allograft rejection is the most significant factor contributing to the development of lymphoceles. Therapy of symptomatic lymphoceles should be individualized according to the presence or absence of infection.

Nonoperative management of post-transplantation bladder leak: serendipitous salutary effect of temporary cyclosporine nephrotoxicity and oligoanuria

Post-transplantation bladder leak, a potentially serious complication, is traditionally managed by reexploration and closure, and may require percutaneous placement of a nephrostomy tube. We report intractable bladder leakage that persisted following reclosure in a patient who also had cyclosporine nephrotoxicity. The attendant oligoanuria obviated the need for nephrostomy drainage and allowed healing of the bladder leak. The patient subsequently recovered from cyclosporine injury and regained renal function.

Treatment of lymphocele and lymphatic fistula following renal transplantation by laparoscopic peritoneal window

Symptomatic lymphoceles that occur after renal transplantation are managed best by surgical marsupialization with drainage into the peritoneal cavity. We report a case of post-transplant lymphocele associated with a cutaneous lymphatic fistula, which was successfully treated using laparoscopic drainage without a major surgical incision. With this new technique we were able to remove an ellipse of peritoneal wall along with the adjacent lymphocele wall and to lyse all internal lymphocele loculations, allowing for the free flow of lymph into the peritoneal cavity and cessation of cutaneous leakage. We believe that, when technically possible, laparoscopic internal peritoneal drainage is an effective procedure for managing simple and complex symptomatic lymphoceles with or without associated lymphatic fistulas, provided there is no evidence of infection.

The mechanism of cyclosporine's action in the inhibition of testosterone biosynthesis by rat Leydig cells in vitro

We have previously demonstrated that cyclosporine inhibits testosterone (T) biosynthesis in vivo. To better understand the mechanism by which CsA inhibits T synthesis, interstitial cells were isolated from rat testes and incubated in the standard medium 199 with or without CsA (0-10 micrograms/ml) in the presence or absence of human chorionic gonadotropin (hCG, 10(-7) M) and 8-bromo cyclic AMP (cAMP, 0.5 mM) for 3 hr at 32 degrees C. The levels of cAMP and T were determined by RIA. CsA did not inhibit the basal secretion of T, but inhibited hCG-stimulated T production in a dose-dependent manner (4 ng/10(6) cells vs. 10 ng/10(6) cells at a CsA dose of 5 micrograms/ml, P less than 0.05). Radioligand binding of 125I-hLH to testicular membranes was not affected by CsA, as CsA did not compete with hCG/LH for binding sites (25-28% binding with or without CsA). Similarly, the MIX-stimulated cAMP production was not affected by CsA (24.03 +/- 1.09 vs. 20.60 +/- 0.38 pmol/10(6) cells), suggesting that CsA does not inhibit the accumulation of the second messenger. However, when interstitial cells were incubated with CsA in the presence of cAMP, a significant dose-dependent decline in T secretion was observed (7 ng/10(6) cells vs. 20 ng/10(6) cells at a CsA dose of 5 micrograms/ml). To determine whether CsA inhibits the steps beyond cAMP stimulation of T secretion, the kinetic parameters (Km and Vmax) of steroidogenic enzymes, delta 4-3 keto-17 alpha hydroxylase (17 alpha-hydroxylase), and delta 4-3 keto-17 beta hydroxy steroid dehydrogenase (17B-HSD) were determined by using Michaelis Menten analysis. Results are shown in the presence of CsA vs. no CsA: Km and Vmax values for 17 alpha-hydroxylase were (2.32 vs. 7.98 microM) and (27.96 vs. 100.97 pmol/mg protein/min), respectively. For 17B-HSD the Km and Vmax were (2.14 vs. 1.52 microM) and (15 vs. 15 pmol/mg protein/min), respectively. These results indicate that CsA inhibits the activity of 17 alpha-hydroxylase uncompetitively and 17B-HSD activity competitively. In conclusion the primary site for CsA inhibition is the cAMP stimulation and, CsA inhibits T synthesis at multiple sites.

Evaluation of the effect of experimental cyclosporine toxicity on male reproduction and renal function. Reversal by concomitant human chorionic gonadotropin administration

Administration of cyclosporine to rats has been shown to impair testicular function, resulting in a decrease in sperm counts and fertility. In order to determine whether or not the deleterious effects of CsA could be reversed by hormonal therapy, mature male Sprague Dawley rats were treated with CsA (40 mg/kg/day, s.c.) alone or in combination with human chorionic gonadotropin (hCG) (5 micrograms/day/r; s.c.) for 14 days. Cyclosporine administration decreased the body weight (290 +/- 5.30 vs. 339 +/- 8.7 g; P less than 0.05) and reproductive organ weights (testis 1.49 +/- 0.42 vs. 1.60 +/- 0.03 g; epididymis 0.41 +/- 0.02 vs. 0.49 +/- 0.002 g; seminal vesicle 0.61 +/- 0.09 vs. 1.60 +/- 0.05 g; prostate 0.28 +/- 0.04 vs. 0.60 +/- 0.06 g; P less than 0.05) testicular sperm counts (5.80 +/- 0.42 vs. 8.49 +/- 0.48 x 10(7)/100 mg tissue; P less than 0.05) and epididymal sperm counts, (28.2 +/- 0.95 vs. 51 51.62 +/- 2.17 x 10(7)/100 mg tissue; P less than 0.05) and fertility (25% vs. 100%). Serum levels of LH were elevated (101.98 +/- 21.48 vs. 25.6 +/- 5.18 ng/ml; P less than 0.05) and testosterone was decreased (0.48 +/- 0.07 vs. 2.06 +/- 0.56 ng/ml; P less than 0.05). The administration of hCG to the CsA-treated rats restored the reproductive organ weights (testis 1.56 +/- 0.043 g; seminal vesicle 1.04 +/- 0.05 g; prostate 0.70 +/- 0.06 g) and sperm counts (testicular 7.88 +/- 1.0 x 10(7)/100 mg tissue; epididymal 59.86 +/- 4.16 x 10(7)/100 mg tissue; P less than 0.05) Serum levels of testosterone (18.63 +/- 4.45 ng/ml) and LH (431.65 +/- 31.41 ng/ml) were significantly elevated, as compared with control and CsA-treated groups (P less than 0.05). All the rats in the gonadotropin-treated group were fertile, as compared with 25% in the CsA-treated group. CsA reduced the kidney weight (1.17 +/- 0.02 vs. 1.27 +/- 0.03 g; P less than 0.05) and increased the levels of serum creatinine (0.97 +/- 0.07 vs. 0.59 +/- 0.03 mg/dl; P less than 0.05): these changes were ameliorated by the administration of hCG (kidney weight 1.35 +/- 0.03 g; creatinine 0.76 +/- 0.09 mg/dl).

Prognostic and therapeutic observations of manifestations in the genitourinary tract of adenocarcinoma of the colon and rectum

To evaluate the significance of involvement of the genitourinary tract in adenocarcinoma of the colon and rectum, we received the records of 178 patients with adenocarcinoma of the colon and rectum admitted to the University of Massachusetts Medical Center from 1980 to 1985. Sixty-eight patients (38 per cent) had urologic manifestations categorized as ureteral obstruction or injury (34 per cent), invasion to the bladder or prostate, or both (10 per cent), isolated gross hematuria (18 per cent), radiation cystitis (6 per cent) and neurogenic bladder (26 per cent). Involvement of the genitourinary tract was more common among patients with recurrent versus primary carcinoma (53 versus 32 per cent) and among patients with high stage (Dukes' C and D) versus low stage (Dukes' A and B) carcinoma (48 versus 21 per cent). The survival rate was worse in patients with high stage compared with low stage disease and no patient with recurrent high stage disease survived beyond three years. Short term survival (less than two years) was not statistically different among patients with or without manifestations in the genitourinary tract: 63 and 45 versus 71 and 66 per cent at one and two years, respectively; however, the five year survival rate was worse among patients with genitourinary involvement (30 versus 54 per cent, p less than 0.05). Surgical and endoscopic intervention of the urinary tract was performed upon 36 patients with Dukes' C and D carcinoma because of life-threatening sepsis or azotemia, or both.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of renal transplantation and dialysis in rehabilitation of diabetic end-stage renal disease patients

We have reviewed the outcome of replacement therapy for end-stage renal disease (ESRD) in 100 diabetic patients with emphasis on late complications, extrarenal diabetic manifestations, and overall patient rehabilitation. Long-term complications, other than myocardial infarction, were not different after renal transplantation compared with chronic dialysis. Overall rehabilitation was better after renal transplantation compared with chronic dialysis (p less than 0.05). Retinopathy and neuropathy were more stable with renal transplantation and peritoneal dialysis compared with hemodialysis (p less than 0.05). These factors should be considered along with expected patient survival when deciding between different treatment modalities for diabetic ESRD.

A critical look at survival of diabetics with end-stage renal disease. Transplantation versus dialysis therapy

The survival of 100 consecutive patients with diabetic nephropathy after treatment with hemodialysis, peritoneal dialysis, or renal transplantation was reviewed at our institution from 1976 to 1982. Standard actuarial survival analysis revealed an overall survival of 83% and 61% at one and two years, respectively. Coronary angiography was used as a screening procedure for renal transplantation. In the dialysis group, 27 patients were considered acceptable transplant candidates on the basis of the coronary angiography but were not transplanted for other reasons. When the survival analysis was limited to those "transplant candidates" the survival rates were 78%, 51%, and 8% at 1, 2, and 5 years, respectively. In comparison, survival after transplantation was 81%, 67%, and 45%, at 1, 2, and 5 years, respectively. In order to eliminate bias, survival comparisons were subsequently made using the Cox Proportional Hazard Model to take into account the time the transplant patients spent on dialysis prior to renal transplantation. When this analysis was performed, there was no significant difference in survival between transplantation and dialysis for the first two years, but overall survival after five years was significantly better after renal transplantation even when the comparison was limited to acceptable transplant candidates who remained on dialysis (P = .04). Survival for patients with significant coronary disease (greater than 70% stenosis of a coronary vessel or moderate to severe left ventricular dysfunction) was analyzed according to therapeutic modality. Although overall prognosis was poor in this group as a whole (1, 2, and 5 year survivals were 76%, 45%, and 19%, respectively), the cardiac patients had a trend to better survival after renal transplantation than when maintained on dialysis (P = .22). In addition to other factors such as quality of life, rehabilitation, and progression of other diabetic complications, the benefit of renal transplantation on patient survival must be considered when deciding between renal transplantation and maintenance dialysis therapy for diabetic patients with renal failure.