Computerized decision support for EPO dosing in hemodialysis patients

BACKGROUND

Anemia management in hemodialysis patients poses significant challenges. The present study explored the hypothesis that computerized dosing of intravenous erythropoietin (EPO) would increase the percentage of hemoglobin (Hb) values within the target range and reduce staff time spent on anemia management.

STUDY DESIGN

Retrospective cohort.

SETTING & PARTICIPANTS

In-center hemodialysis patients who received EPO at Dialysis Clinic Inc dialysis units for at least 3 months between October 1, 2005, and April 30, 2006.

QUALITY IMPROVEMENT PLAN

Computerized decision support (CDS) for EPO dosing is compared with manual physician-directed dosing.

OUTCOMES

Achieved monthly Hb values, quantity of EPO administered, and time spent by dialysis unit personnel.

MEASUREMENTS

Monthly Hb and quantity of EPO administered to 1,118 patients from 18 dialysis units treated using CDS and 7,823 patients from 125 dialysis units treated using manual dosing.

RESULTS

There was no difference in the likelihood of a monthly Hb level of 11-12 or 10-12 g/dL using CDS compared with manual dosing. The likelihood of an Hb level > 12 g/dL decreased and the likelihood of an Hb level < 10 g/dL increased using CDS. EPO use was 4% lower using CDS, although the difference was not statistically significant. CDS was associated with a nearly 50% decrease (P < 0.001) in the time spent by dialysis unit staff on anemia management.

LIMITATIONS

Retrospective and nonrandomized.

CONCLUSION

The number of monthly Hb values in an 11- (and 10-) to 12-g/dL target range and EPO use did not differ with EPO dosing using CDS compared with manual dosing. Staff resources devoted to anemia management decreased significantly using CDS.

Mortality risk among hemodialysis patients receiving different vitamin D analogs

Intravenous vitamin D is standard therapy for secondary hyperparathyroidism in hemodialysis (HD) patients. In for-profit dialysis clinics, mortality was higher for patients on calcitriol compared to paricalcitol. Doxercalciferol, a second vitamin D2 analog, is currently available. We assessed mortality associated with each vitamin D analog and with lack of vitamin D therapy in patients who began HD at Dialysis Clinic Inc. (DCI), a not-for-profit dialysis provider. During the 1999-2004 study period we studied 7731 patients (calcitriol: n=3212; paricalcitol: n=2087; doxercalciferol: n=2432). Median follow-up was 37 weeks. Mortality rates (deaths/100 patient-years) were identical in patients on doxercalciferol (15.4, 95% confidence interval (13.6-17.1)) and paricalcitol (15.3 (13.6-16.9)) and higher in patients on calcitriol (19.6 (18.2-21.1)) (P<0.0001). In all models mortality was similar for paricalcitol versus doxercalciferol (hazard ratios=1.0). In unadjusted models, mortality was lower in patients on doxercalciferol (0.80 (0.66, 0.96)) and paricalcitol (0.79 (0.68, 0.92)) versus calcitriol (P<0.05). In adjusted models, this difference was not statistically significant. In all models mortality was higher for patients who did not receive vitamin D versus those who did (1.2 (1.1-1.3)). Mortality in doxercalciferol- and paricalcitol-treated patients was virtually identical. Differences in survival between vitamin D2 and D3 may be smaller than previously reported.

Retail cutting characteristics for US Choice and US Select beef subprimals

US Choice (Ch) and US Select (Se) beef subprimals from the rib, chuck, plate, loin, and round were obtained to conduct retail cutting tests. Subprimals were merchandised into bone-in or boneless retail cuts and associated components by experienced retail meat merchandisers. These Se subprimals had less (P<0.05) trimmable fat than their Ch counterparts: ball tip, top sirloin, outside round, inside round, and ribeye. Se inside rounds, outside rounds, eye of rounds, boneless striploins, and ball tips had greater (P<0.05) purge losses than the same cuts from Ch. The only subprimals where grade impacted total saleable yield were the top (inside) rounds (Ch=80.13%, Se=87.34%; P=0.004) and outside rounds cut into roasts, steaks, and cubed steaks (Ch=87.61%, Se=90.28%; P=0.05). Methods to increase retail yields from beef subprimals should consider minimizing purge and increasing cutting efficiencies in addition to reducing fat trim.

Retail yields from beef chuck and round subprimals from two grade groups when merchandised as single muscle cuts

Beef subprimals from two different grade groups were obtained from two beef processors to assist in updating the Beef Computer Assisted Retail Decision Support (CARDS) program with new fabrication styles. The grade groups consisted of Top Choice (containing subprimals from carcasses with a Modest or Moderate degree of marbling) and Select (containing subprimals from carcasses with a Slight degree of marbling). Subprimals (shoulder clod; top blade, roast; arm roast; knuckle, peeled; outside round, flat) were separated into individual muscles and fabricated into retail cuts by professional retail meat cutters. Mean retail cutting yields and labor requirements were calculated from observed weights (kilograms) and processing times (seconds). Data were analyzed to determine means and standard errors of percentage yield and processing times for subprimals in each grade group, and comparisons were made between grade groups. Generally, there were few differences in processing times between Top Choice and Select subprimals, and the trimming phase required the most time to complete for each subprimal. Differences (P < 0.05) were observed in saleable yield between Top Choice and Select subprimals for the shoulder clod (Top Choice = 73.89%; Select = 78.49%), top blade, roast (Top Choice = 84.36%; Select = 86.70%), and outside round, flat (Top Choice = 85.99%; Select = 91.34%). Trimmable fat differed (P < 0.05) between Top Choice and Select subprimals: shoulder clod (Top Choice = 25.30%; Select = 20.85%), top blade, roast (Top Choice = 14.88%; Select = 12.59%), arm roast (Top Choice = 8.35%; Select = 7.47%), knuckle (Top Choice = 5.72%; Select = 2.73%), and outside round, flat (Top Choice = 13.82%; Select = 7.26%). Most of the differences in saleable yields were related to less trimmable fat for Select subprimals, which also required less trimming time than Top Choice subprimals. These data will serve to update the Beef CARDS program and will provide retailers and foodservice operators with third-party cutting yield and time allocation information.

Foodservice yield and fabrication times for beef as influenced by purchasing options and merchandising styles

Selected beef subprimals were obtained from fabrication lines of three foodservice purveyors to assist in the development of a software support program for the beef foodservice industry. Subprimals were fabricated into bone-in or boneless foodservice ready-to-cook portion-sized cuts and associated components by professional meat cutters. Each subprimal was cut to generate mean foodservice cutting yields and labor requirements, which were calculated from observed weights (kilograms) and processing times (seconds). Once fabrication was completed, data were analyzed to determine means and standard errors of percentage yields and processing times for each subprimal. Subprimals cut to only one end point were evaluated for mean foodservice yields and processing times, but no comparisons were made within subprimal. However, those traditionally cut into various end points were additionally compared by cutting style. Subprimals cut by a single cutting style included rib, roast-ready; ribeye roll, lip-on, bone-in; brisket, deckle-off, boneless; top (inside) round; and bottom sirloin butt, flap, boneless. Subprimals cut into multiple end points or styles included ribeye, lip-on; top sirloin, cap; tenderloin butt, defatted; shortloin, short-cut; strip loin, boneless; top sirloin butt, boneless; and tenderloin, full, side muscle on, defatted. Mean yields of portion cuts, and mean fabrication times required to manufacture these cuts differed (P < 0.05) by cutting specification of the final product. In general, as the target portion size of fabricated steaks decreased, the mean number of steaks derived from any given subprimal cut increased, causing total foodservice yield to decrease and total processing time to increase. Therefore, an inverse relationship tended to exist between processing times and foodservice yields. With a method of accurately evaluating various beef purchase options, such as traditional commodity subprimals, closely trimmed subprimals, and pre-cut portion steaks in terms of yield and labor cost, foodservice operators will be better equipped to decide what option is more viable for their operation.

"U" curve association of blood pressure and mortality in hemodialysis patients. Medical Directors of Dialysis Clinic, Inc

BACKGROUND

Hypertension may play an important role in the pathogenesis of the excess cardiovascular and cerebrovascular (CV) morbidity observed in hemodialysis patients (HD). However, the optimal blood pressure (BP) range for HD patients has not been defined. We postulated that there is a "U" curve relationship between BP and CV mortality. To explore this hypothesis we studied 5,433 HD patients in Dialysis Clinic Inc., a large not-for-profit chain, over a five year period.

METHODS

Cox regression, with fixed and time-varying covariates, was used to assess the effect of systolic blood pressure (SBP) and diastolic blood pressure (DBP), pre- and post-dialysis, on CV mortality, while adjusting for age, gender, ethnicity, primary cause of end-stage renal disease, Kt/V, serum albumin, and antihypertensive medications.

RESULTS

The overall impact of BP on CV mortality was modest. Pre-dialysis, neither systolic nor diastolic hypertension were associated with an increase in CV mortality. Post-dialysis, SBP > or = 180 mm Hg (RR = 1.96, P < 0.015) and DBP > or = 90 mm Hg (RR = 1.73, P < 0.05) were associated with increased CV mortality. Low SBP (SBP < 110 mm Hg) was associated with increased CV mortality, pre- and post-dialysis.

CONCLUSIONS

The results suggest the presence of a "U" curve relationship between SBP post-dialysis and CV mortality in HD patients.

Retail yield and fabrication times for veal as influenced by purchasing options and merchandising styles

Twenty-nine selected styles of subprimals or sections of veal were obtained from a commercial facility to assist in the development of a support program for retailers. They were fabricated into bone-in or boneless retail cuts and associated components by trained meat cutters. Each style selected (n = 6) was used to generate mean retail yields and labor requirements, which were calculated from wholesale and retail weights and processing times. Means and standard errors for veal ribs consisting of five different styles (n = 30) concluded that style #2, 7-rib 4 (10 cm) x 4 (10 cm), had the lowest percentage of total retail yield (P < .05) owing to the greatest percentage of bone. Furthermore, rib style #2 required the longest total processing time (P < .05). Rib styles #3, 7-rib chop-ready, and #5, 6-rib chop ready, yielded the greatest percentage of total retail yield and also had the shortest total processing time (P < .05). Within veal loins, style #2, 4 (10 cm) x 4 (10 cm) loin kidney fat in, had the greatest percentage fat (P < .05). Loin styles #2 and #3, 4 (10 cm) x 4 (10 cm) loin special trimmed, generated more lean and fat trimmings and bone, resulting in lower percentage of total retail yields than loin style #1, 0 (0 cm) x 1 (2.5 cm) loin special trimmed (P < .05). Results indicated that bone-in subprimals and sections required more processing time if fabricated into a boneless end point. In addition, as the number of different retail cuts increased, processing times also increased.

Long-term renal function in heart transplant recipients receiving cyclosporine therapy

BACKGROUND

Immunosuppression with cyclosporine has improved allograft function and reduced both morbidity and mortality in organ transplantation. However, cyclosporine-induced nephrotoxicity still is a concern. The purpose of our study was to evaluate the effects of cyclosporine on renal function in orthotopic heart transplant recipients.

METHODS

Thirty-nine patients who received transplants from 1985 to 1991 and had at least three yearly glomerular filtration rate measurements posttransplantation by 125I-iothalamate clearance method were included in the study. In addition, serum creatinine (before and after transplantation) and cyclosporine doses were analyzed.

RESULTS

Maintenance immunosuppression at 1 year consisted of prednisone (0.1 mg/kg/day), azathioprine (2 mg/kg/day), and cyclosporine (12-hour trough level 100 to 150 ng/ml by fluorescence polarization immunoassay). The mean serum creatinine at 1 year was significantly higher than the mean pretransplantation serum creatinine (1.51 +/- 0.32 versus 1.28 +/- 0.38, p < 0.05) and stabilized after the first year. The mean glomerular filtration rate by 125I-iothalamate clearance method was 70.6 +/- 20.3 ml/min/1.73 m2 (range 32 to 105) at 1 year and remained relatively stable during the follow-up period of up to 7 years. Creatinine clearance calculated by the Cockcroft and Gault formula overestimated the true glomerular filtration rate after the third year. The mean cyclosporine dosage was significantly lower after the first-year dose of 3.9 +/- 1.8 mg/kg/day (p < 0.05). Three patients in 39 started hemodialysis at 5, 7, and 10 years after transplantation.

CONCLUSION

Our data indicate that the adequacy of renal function is preserved with long-term cyclosporine therapy in heart transplant recipients.

Influence of wholesale lamb marketing options and merchandising styles on retail yield and fabrication time

Lamb carcasses (n = 94) from five packing plants, selected to vary in weight class and fat thickness, were used to determine retail yield and labor requirements of wholesale lamb fabrication. Carcasses were allotted randomly according to weight class to be fabricated as whole carcasses (n = 20), three-piece boxes (n = 22), or subprimals (n = 52). Processing times (seconds) were recorded and wholesale and retail weights (kilograms) were obtained to calculate retail yield. Subprimals were fabricated into bone-in retail cuts or boneless or semi-boneless retail cuts. Retail yield for subprimal lamb legs decreased from 85.3 +/- .6% for bone-in to 68.0 +/- .7% for a completely boneless retail product. Correspondingly, processing times increased from 126.1 +/- 5.4 s to 542.0 +/- 19.2 s for bone-in and boneless legs, respectively. For all subprimals, retail yield percentage tended to decrease and total processing time increase as cuts were fabricated to boneless or semi-boneless end points compared with a bone-in end point. Percentage retail yield did not differ (P > .05) among whole carcass, three-piece box, and subprimal marketing methods. Total processing time was shorter for subprimals (P < .05) than for the other two marketing methods.

Subprimal purchasing and merchandising decisions for pork: relationship to retail yield and fabrication time

Boxed pork was obtained to represent four different purchase specifications (different anatomical separation locations and[or] external fat trim levels) common in the pork industry to conduct a study of retail yields and labor requirements. Bone-in loins (n = 180), boneless loins (n = 94), and Boston butts (n = 148) were assigned randomly to fabrication styles within subprimals. When comparing cutting styles within subprimals, it was evident that cutting style affected percentage of retail yield and cutting time. When more bone-in cuts were prepared from bone-in loin subprimals, retail yields ranged from 92.80 +/- .61 to 95.28 +/- .45%, and processing times ranged from 222.57 +/- 10.13 to 318.99 +/- 7.85 s, from the four suppliers. When more boneless cuts were prepared from bone-in loin subprimals, retail yields ranged from 71.12 +/- 1.10 to 77.92 +/- .77% and processing times ranged from 453.49 +/- 8.95 to 631.09 +/- 15.04 s from the different loins. Comparing boneless to bone-in cuts from bone-in loins resulted in lower yields and required greater processing times. Significant variations in yields and times were found within cutting styles. These differences seemed to have been the result of variation in supplier fat trim level and anatomical separation (primarily scribe length).

Subprimal purchasing and merchandising decisions for pork: relationship to retail value

To assess retail value and profitability, cutting test data were obtained in a simulated retail cutting room for boxed pork subprimals, bone-in loins (n = 180), boneless loins (n = 94), Boston butts (n = 148), fresh hams (n = 28), and boneless hams (n = 23). Processing times (seconds) and retail weights (kilograms) were used to determine relative value. Cutting style affected (P < .05) value differential (US$/subprimal) for bone-in and boneless loins. When cutting styles within subprimals were pooled, value differential was affected (P < .05) by purchasing specification for bone-in loins, boneless loins, Boston butts, and inside fresh hams. Processing bone-in loins to a boneless end point produced a greater (P < .05) value differential and percentage of gross margin than a bone-in retail end point. Bone-in loins fabricated to a boneless retail end point produced a greater (P < .05) value differential and percentage of gross margin than boneless loins fabricated to the same end point. The increase in retail value can be attributed to the increased number and weight of retail cuts produced from bone-in loins. The thick, boneless loin cutting style produced a greater (P < .05) value differential and percentage of gross margin as a result of a lower (P < .05) cost of fabrication and increased value of retail cuts than the thin, boneless cutting style. In general, boneless pork cutting methods were more profitable than bone-in cutting methods regardless of subprimal.

Disseminated histoplasmosis presenting as urinary tract obstruction in a renal transplant recipient

Disseminated histoplasmosis occasionally involves the kidney, but the infection usually does not cause either urinary symptoms or a decrease in renal function. We present a case of disseminated histoplasmosis in a renal transplant recipient who presented with urinary obstruction in the allograft from a sloughed renal papilla infected with the fungus. At the same time the patient had chronic meningitis from Histoplasma capsulatum. The literature on renal involvement with histoplasmosis is reviewed.

Yield grade and carcass weight effects on the cutability of lamb carcasses fabricated into innovative style subprimals

Lamb carcass (n = 100) were selected from USDA yield grades (YG) 2, 3, and 4 and carcass weight (CW) groups 20.4 to 24.9, 25.0 to 29.5, and 29.6 to 34.0 kg. Lamb carcass were fabricated into semiboneless and boneless subprimals and trimmed to three s.c. fat trim levels: .64, .25, and .00 cm of fat remaining. Innovative subprimals were fabricated and yields were calculated for the subprimals and dissectible components (lean, bone, connective tissue, external fat, and seam fat) from each of the various subprimals. Carcass weight as a main effect in a two-way analysis of variance did not account for a significant amount of the variation in yield among trimmed subprimals or the percentage of the dissectible components, but USDA YG was a significant main effect in determining variation in yield for many of the subprimals or dissectible components. Muscle seaming of shoulders and legs and removal of excessive tails on the loin and rack resulted in a majority of the seam fat being removed from these cuts. Dissection data clearly showed that seam fat is a major component of rack and shoulder cuts and with increasing fatness or higher numerical yield grade there are clearly increased amounts of this depot. Increased trimming of external fat magnifies and draws more attention to the amount of seam fat remaining. Production of heavy, lean lambs would be more useful in an innovative type of program because of the larger-sized muscles. Heavy, fat lambs would not be as useful because of their decreased yields and excess seam fat located in cuts that cannot be muscled-seamed because of the loss of retail cut integrity. Seam fat was highly correlated to percentage of kidney and pelvic fat and to external fat thickness and with USDA yield grade but was not strongly correlated to carcass weight.

The effect of polyimmune gammaglobulin for prophylaxis against reactivation cytomegalovirus infection in kidney and kidney/pancreas transplant recipients

Cytomegalovirus (CMV) remains the most important infection in the renal transplant recipient. Few data are available that provide guidance for approaches that seek to reduce the reactivation of latent disease after transplantation. To test the efficacy of polyimmune gammaglobulin in kidney and kidney/pancreas transplantation, consenting recipients with serologic evidence of previous CMV disease were randomized to receive i.v. polyimmune gammaglobulin (500 mg/kg) within 3 days of transplant with 250 mg/kg at weeks 1, 2, 4, and 6 or no prophylaxis. Both groups received identical induction and rejection immunosuppressive therapy. Polyimmune gammaglobulin prophylaxis reduced CMV reactivation infections. The incidence of reactivation infections was half in patients receiving Nashville/rabbit antithymocyte serum (N/R-ATS) compared with those receiving monoclonal anti-CD-3 therapy. Patients receiving polyimmune gammaglobulin along with N/R-ATS had an incidence of infection of only 10%. Reactivation infections were twice as common in patients who had primary nonfunction and nearly three times as common in patients with acute rejection. Both risk factors were associated with longer anti-T-cell therapy. Polyimmune gammaglobulin prophylaxis should be considered in transplant patients with previous CMV exposure who will be receiving prolonged anti-T-cell therapy because of acute rejection or primary nonfunction.

Colonic screening prior to renal transplantation and its impact on post-transplant colonic complications

Colonic complications after renal transplantation are uncommon but have a high mortality rate. Some have recommended colonic screening in patients over 50 years of age prior to transplantation to lessen the impact of colonic diverticular disease. We report our 9-year experience of colonic screening for diverticular disease in potential recipients over the age of 50 and compare these results to the overall colonic complication rate in the same time period. From 1981-1990, 1186 renal transplants in 1019 patients were performed, during which time all potential recipients over the age of 50 yr were required to undergo colon evaluation prior to transplantation. Twenty cases of diverticular disease were found with more than a quarter of the cases in patients with adult polycystic disease. All underwent renal transplantation without a pre-transplant colectomy, and none had post transplant symptomatic colon disease. During that same time period a total of 14 colonic complications requiring surgical intervention were encountered with a mortality rate of 40%. Acute diverticulitis occurred in 5 patients, all of whom were over 50 yr of age, on low-dose immunosuppression, and in most cases it occurred remotely after transplantation. Colonic dysplasia/neoplasia also occurred remotely after transplantation in 2 patients over the age of 50. Cytomegalovirus (CMV) colitis was the next most common complication, accounting for 3 cases. This complication, which occurred in younger patients, was associated with high-dose steroid immunosuppression and had a high mortality rate, in spite of surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Distribution and vasomotor effects of neuropeptides in angular oculi and facial veins of reindeer

1. The vasomotor responses to neuropeptides of the angular oculi and facial veins of reindeer were examined in vitro and correlated with the neuropeptide distribution in the perivascular nerves, as demonstrated by immunohistochemistry. 2. Nerves displaying calcitonin gene related peptide (CGRP)- or neuropeptide Y (NPY)-like immunoreactivity (-LI) were observed in the media of both veins, while very few fibers were immunoreactive to vasoactive intestinal polypeptide (VIP) or substance P (SP) in either vein. 3. The staining pattern for NPY-LI was largely identical to that of dopamine-beta-hydroxylase, a marker for noradrenaline (NA) producing fibers, indicating coexistence of NPY and NA. 4. Administration of NPY in vitro elicited contractions in both veins in the presence of propranolol, though more conspicuously in the angular oculi vein. 5. The peptide was without any modulating effect on NA-stimulated contractions in the angular oculi vein, whereas a small enhancement of the NA-induced tone was seen in the facial vein. 6. CGRP caused partial relaxation of both veins, whereas atrial natriuretic polypeptide caused relaxation only in the facial vein. VIP and SP had no effect on either vein. 7. The results suggest that in reindeer the sympathetic nerve fibres to both facial and angular oculi veins contain the vasoconstrictor neuropeptide NPY besides NA, even though these fibres exert a vasodilator action on the myogenically active facial vein. 8. The vasodilator neuropeptide CGRP, which is present in other more sparse perivascular nerve fibres mainly in angular oculi vein, is perhaps of afferent nature in which case CGRP might subserve axon reflex functions. 9. If, however, also the CGRP fibres are truly efferent in nature, chances for a central reciprocal control of flow through angular oculi vein might be at hand.

Presymptomatic testing for adult onset polycystic kidney disease in at-risk kidney transplant donors

Autosomal dominant adult-onset polycystic kidney disease (ADPKD) is estimated to have an incidence of 1/1,000 and accounts for approximately 10% of all end-stage renal disease in the United States. While relatives are attractive as renal donors due to their availability and the improved transplant success associated with living-related donors, they may coincidentally be at risk for ADPKD. Accurate presymptomatic testing for at-risk potential donors is critical for both the donor and the recipient. We report here 2 families in which presymptomatic testing for ADPKD was accomplished by DNA linkage analysis on several potential renal donors prior to transplant. This resulted in the protection of both donors and recipients by preventing the transplantation of a kidney affected by ADPKD. Thorough counseling prior to DNA analysis (including discussion of accuracy and possible testing outcomes of presymptomatic diagnosis of ADPKD, diagnosis of noncarrier status, false paternity, and non-informative study) was essential to provide informed consent and preserve confidentiality within the family. Confidentiality for potential donors found presymptomatically to be affected (with a 94% or greater probability) was especially difficult to maintain.

Single-center analysis of impact of immunosuppressive therapy upon renal allograft survival in the black population

The effect of race upon renal allograft survival is controversial. Between 1981 and 1987, at Vanderbilt University Medical Center, 448 patients (75 black, 373 white) received azathioprine, 3 mg/kg daily; prednisone, 30 mg daily; and intravenous antithymocyte sera, 0.2 mL/kg/day for 14 days, after transplantation. Prednisone doses were decreased gradually to 10 mg daily within 6 months of transplantation. Azathioprine was maintained at doses of 2 to 3 mg/kg/daily; lower doses were administered if significant myelosuppression occurred. One-year graft survival was 72% and 85% among black and white recipients, respectively (P less than .01). Two hundred thirty-six patients have been treated with azathioprine (3 mg/kg initially tapered during the first week to 1.5 to 2 mg/kg); prednisone, 30 mg daily; and cyclosporine, 10 mg/kg per day. Cyclosporine therapy was begun after recipient serum creatinine levels had decreased below 3 mg/dL. Before therapy was initiated and until levels of cyclosporine were maintained between 150 and 200 ng/mL (whole blood), antithymocyte serum was administered. This immunosuppressive protocol resulted in 1-year graft survival of 90% and 87% in black and white recipients, respectively. Not only was graft loss markedly reduced, but the interracial difference noted before the use of cyclosporine was no longer evident. The type of immunosuppressive therapy used clearly affected 1-year allograft survival among black recipients. The combination of azathioprine, cyclosporine, and prednisone resulted in improved graft survival overall, but had the most significant effect among blacks.

Vascular control of brain cooling in reindeer

The cold venous effluent returning from the nose of the heat-stressed reindeer may be distributed through angular oculi veins for selective cooling of the brain and through facial veins for general body cooling. In vitro experiments indicate that adrenergic receptors of the angular oculi vein are exclusively of the alpha-adrenergic type, whereas facial veins contain mainly beta-adrenergic receptors. We suggest that the antagonistic adrenergic neuroeffector organization of these veins plays a major role in control of brain cooling. Thus simultaneous sympathetic stimulation results in constriction of angular oculi veins and release of a preexisting stretch-induced tone in facial veins. In this situation cold venous blood is directed via facial veins and used for general body cooling. Reduction of sympathetic activity, on the other hand, results in dilatation of angular oculi veins and constriction of facial veins, due to development of myogenic tone in the latter vessels. In this situation cold venous blood is distributed via angular oculi veins and used for selective cooling of the brain.

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.

Renal transplantation. A 20-year experience in a Veterans Administration Medical Center

Between March 1963 and December 1983, 324 renal transplants were performed in 273 veteran patients at the Veterans Administration Medical Center, Nashville, Tenn. Cadaver donors were used in 273 transplants, with an overall one-year patient survival of 72.5% and one-year functional graft survival of 50%. Twenty-four living-related transplants were performed, with an overall one-year patient survival of 89% and one-year functional graft survival of 75%. For analytical purposes the 20-year transplant experience was divided into five eras. One-year patient survival increased from 45% in era 1 to 84% in era 5, while functional graft survival increased from 45% to 70%. Death has occurred in 139 patients, with sepsis being responsible for the largest number of early deaths. Cardiovascular disease was responsible for most late deaths.

Neoplasia in immunosuppressed renal transplant patients: a 20-year experience

This review examines a 20-year experience in renal transplantation at our center to determine the effects of immunosuppression on the subsequent development of malignancies. Twenty patients had 21 malignancies from primary sites other than skin, yielding an incidence of 2.5%. There were 0.65 malignancies for each 100 cumulative patient years of immunosuppression. Suppression of the host immune response is associated with an increased incidence of malignancies.

Bilateral nephrectomy concomitantly with renal transplantation

During a 2-year interval 206 patients underwent renal transplantation at a single center, 38 of whom underwent bilateral nephrectomy and other adjuvant operations as part of the transplant procedure. The indications for this type of procedure were reviewed, with special emphasis on the control of hypertension. The morbidity and mortality (16 per cent) in this group were compared in detail to those in patients not undergoing a concomitant adjuvant operation. The results with regard to renal function were similar to the group as a whole and the indications for appropriate patient selection are discussed.

Invasive aspergillosis in renal transplant recipients: correlation with corticosteroid therapy

During a 31-month period in 1979-1981, nine patients at a renal transplant center in Tennessee developed invasive infections with Aspergillus species. Despite an extensive search, no common environmental source of contamination was found. A matched case-control study of host risk factors showed that leukopenia, prior administration of antibiotics, and treatment with azathioprine and antilymphocyte serum were not significantly related to the development of aspergillosis. In contrast, the administration of high-dose corticosteroids posed a significant risk. An average daily dose of greater than or equal to 1.25 mg of prednisone/kg per day for the entire interval studied was the best predictor of subsequent invasive infection with Aspergillus.

Factors influencing the outcome of kidney transplants

This study is a multifactorial analysis of 389 transplants performed from June 1977 to December 1981. Analysis of the effects of transfusions antilymphocyte serum (ALS), histocompatibility testing, gender, and patient risk factors (presence of concomitant disease, greater than 50 years of age, etc.) was done. Two-hundred fifty-three patients received cadaver kidneys and 136 patients obtained kidneys from a relative. Two-hundred eighty-three (73%) patients received blood transfusions prior to transplantation. Our data showed that recipients receiving transfusions prior to transplantation had a significantly higher graft survival than those who were not transfused in both cadaveric and related graft recipients. Two-hundred twenty-one (56%) patients received ALS following the transplant. This group had a 15% higher graft survival than a comparable group. Analysis of histocompatibility testing data shows approximately 5% higher functional graft survival between each match grade. Surprisingly, female patients receiving kidneys from living related donors had a 16% higher graft survival than male patients. In cadaver recipients female patients had a 10% higher patient survival as compared to male patients. The risk factor status of recipients affected not only graft survival but patient survival, which probably is due to the consequences of immunotherapy. The authors' conclusion is that the above mentioned factors may be additive in nature. Further, multivariable analysis is necessary in order to correctly transplant data.

Renal transplant arterial stenosis: percutaneous transluminal angioplasty

Seven hypertensive patients underwent percutaneous transluminal angioplasty for relief of arterial stenosis complicating renal allotransplantation. Five had end-to-side anastomosis of the donor renal artery to the recipient external iliac artery, and two had end-to-end anastomosis of the donor renal artery to the recipient internal iliac artery. Each patient had developed hypertension (blood pressure greater than 145/95 mm Hg), elevated peripheral venous plasma renin, and six demonstrated decrease in renal function as detected by an increase in serum creatinine at least 2 months after transplantation and without evidence of rejection. Angioplasty was technically successful without significant complications and blood pressure and biochemical abnormalities were improved or stabilized in all seven patients.

Effects of Sodium Nitrite, Sodium Chloride, Heating and Freezing on Survival of Trichinae in Hams

Two experiments were conducted to determine the effects of sodium chloride, sodium nitrite, heating and/or freezing on viability of trichinae in hams. The most effective treatment for destroying trichinae consisted of pumping hams with a curing solution containing 2.6% sodium chloride and 156 ppm sodium nitrite followed by heating of hams to 43.3°C. Six days of storage at -29°C were required to achieve 100% destruction of trichinae for control (not pumped, not heated) hams. Seven, 8 and 8 d, respectively, were required to achieve 100% destruction of trichinae for those hams that were not heated but pumped without sodium chloride or sodium nitrite, or those that were pumped with solutions containing either 1.6% sodium chloride and 120 ppm sodium nitrite or 2.6% sodium chloride and 156 ppm sodium nitrite.

Partial splenic embolization for hypersplenism in renal transplantation

Immunosuppressive therapy is necessary in the treatment and prevention of rejection in renal transplant recipients. Unfortunately, these patients may become intolerant to this therapy when it is complicated by hypersplenism with leukopenia and/or thrombocytopenia. The therapy must then be either decreased or stopped, thus preventing adequate treatment or prevention or rejection. Splenectomy has been used to treat the hypersplenism to break this cycle. It requires operative intervention with general anesthesia and prolonged hospitalization, and has been associated with fulminant bacterial septicemia. For these reasons, partial splenic embolization was offered to our patients as an alternative to splenectomy in the treatment of their immunosuppressive therapy intolerance due to hypersplenism. Six patients with acute rejection episodes and one patient on dialysis awaiting transplantation underwent partial splenic embolization. It corrected the hypersplenism in each case without significant complications allowing control of the rejection episode with adequate immunosuppressive therapy in six patients. Strict aseptic technique, pain control, and antibiotic prophylaxis are advised to prevent the complications of splenic abscess, rupture, or septicemia when this technique is used.

Effect of Chloride Salts and Nitrite on Survival of Trichina Larvae and Other Properties of Pork Sausages

Two experiments were conducted using trichinae-infected pork shoulders. In the first experiment, samples of ground pork shoulder were allocated to the following treatments: (a) sodium nitrite levels of 0, 75 or 150 ppm, and (b) chloride salt levels of 2.5% sodium chloride, 3.18% potassium chloride, 1.35% magnesium chloride and 1.58% calcium chloride (for the latter three chloride salts, ionic strengths equivalent to that of 2.5% sodium chloride were used). In the second experiment, samples of ground pork shoulder were allocated to treatments in which 0, 25, 50, 75 or 100% of the sodium chloride was replaced with a 70:30 mixture of magnesium chloride: potassium chloride. Pork sausage links were made and stored for 12 d in a refrigerated display case. All chloride salts numerically reduced total plate counts compared to controls (no added salts) and calcium chloride or magnesium chloride significantly reduced total plate counts (P<.05). However, addition of sodium nitrite (75 or 150 ppm) did not affect total plate counts. Percentages of dead trichina larvae (visually determined) were greater (P<.05) for potassium chloride and sodium chloride than for magnesium or calcium chloride. However, in the second study when salts of equivalent ionic strengths were not used, replacement of sodium chloride with a 70:30 mixture of magnesium chloride: potassium chloride did not affect (increase or decrease) pH, total plate count or juice-loss during cooking. Percentages of dead trichina larvae increased for the 75 and 100% replacement levels when compared to controls.

Three simple solutions for renal flush and preservation

The harvesting of kidneys at small hospitals where standard flush solutions are not available has led to the use of several flush solutions that can be made from readily available materials. Mongrel dogs (15) had bilateral nephrectomy after receiving intravenously a mixture of Ringer's lactate, furosemide (Lasix), mannitol, and chlorpromazine (Thorazine). One kidney was perfused with iced Collins' solution and stored for 24 hours, submerged in the perfusate at 4 C. Five dogs each had the contralateral kidney perfused with a solution of either (1) Ringer's lactate, salt-poor albumin, and heparin; (2) 6% dextran 70 and Fenwall buffered heparin solution; or (3) Ringer's lactate, mannitol, and heparin, and were stored in their respective perfusate. After 24 hours' storage the kidneys were transplanted into the neck, and creatinine clearance (Crcl) was determined on days 1, 2, 3, 5, and 7. The dogs were sacrificed on day 7 and biopsy specimens were obtained from each kidney for pathologic examination. The kidneys perfused with Collins' solution had immediate function after transplantation with an average Crcl of 10.5 at 25 hours and 20.2 at seven days. The kidneys perfused with Ringer's lactate and albumin had minimal function immediately after transplantation and were anuric within 24 hours. The kidneys perfused with dextran solution and Ringer's lactate and mannitol solution had immediate function but output remained low, and by seven days the average Crcl was only 3.0 and 4.5 respectively. All solutions except the Ringer's lactate and albumin were hyperosmolar, thus helping to prevent the "no reflow" phenomenon. These results indicate that the solutions tested do not result in the adequate preservation to warrant clinical use.

Cryptococcal septicemia associated with urologic instrumentation in a renal allograft recipient

A case is presented of a renal allograft recipient with 2 episodes of cryptococcal septicemia temporally related to genitourinary manipulation, which preceded the usual signs of meningeal or cutaneous infection. A review of the literature suggests that cryptococcal disease may, occasionally, manifest itself initially in the genitourinary tract. Therefore, we suggest that cryptococcal infection be suspected in the compromised host who has symptoms of cystitis or bladder outlet obstruction during a short period.

The use of bactericidal concentrations of antibiotics in hypothermic pulsatile perfusion and the effects on canine renal autograft function

Although cadaver allograft contamination occurs frequently, the potential danger to the transplant recipient varies. Usually the results of culture from the donor and kidney perfusates are not available at the time of transplantation. A positive culture result often necessitates the use of prophylactic antibiotics. The antibiotic may be potentially nephrotoxic, and in the setting of minimal or changing renal function this effect may be potentiated. If significant contamination with virulent organisms is found prior to transplantation, clinical judgment often dictates that the graft be discarded. Perfusion and storage with solutions containing broad-spectrum antibiotics would substantially reduce the incidence of contamination in perfused kidneys. This would in turn reduce the requirement for potentially nephrotoxic antimicrobial therapy in the transplant recipient. Since the antibiotics tested are effective against a wide range of contaminants and apparently cause no detrimental effects, it would seem reasonable to add them routinely to the perfusate solution.