Renal transplantation for progressive systemic sclerosis with renal failure: case report and review of previous experience.

Renal transplantation for terminal renal failure as a result of scleroderma (progressive systemic sclerosis [PSS]) seems justified if other organs have not been severely damaged by the disease. The recurrence of PSS in the graft, not observed in early reports, appears to have caused the rapid failure of a cadaveric graft in a forty year old woman with acute PSS. A similar case of rapid PSS recurrence in the transplant has been recently reported by others [7]. A more aggressive pattern of PSS seems to differentiate these two patients in whom recurrence was observed from four previous patients with long-term graft functions. The possibility of rapid renal transplant loss should be considered in the selection and prognosis of acute PSS patients.

Electrical potential of gastroduodenal mucosa measured by endoscopy.

The gastroduodenal mucosa has a negative electrical potential with regard to the blood stream, as measured by a potentiometer connected to an intravenous and an intragastric electrode. The intragastric electrode can be positioned on various points of the gastroduodenal surface under direct vision through the forceps channel of the gastroduodenoscope. The values of potential differences were determined in various areas of the stomach and duodenum of normal humans and also over gastric ulcers, duodenal ulcers, gastritis and gastric erosions. A deflection of the potential difference value toward zero characterizes any disruption of the normal mucosa, even if only a few millimeters in diameter. Localized reproduce localized potential difference deflections. Atrophic lesions are represented by larger areas of abnormal potential difference levels. The direct multiple determinations of potential differences over mucosal areas in which lesions are suspected is a useful, simple tool for more objective gastroduodenoscopic diagnoses.

Late hypertension in renal transplant recipients: possible role of the donor in late primary hypertension.

Late onset (3-7 yrs) post-transplant renal hypertension is usually an indication of chronic, irreversible renal damage, and is a poor prognostic sign. In a small percent of patients (10%) however, hypertension can persist for years in conjunction with excellent renal function, and the absence of any known causes of early or late hypertension. This primary hypertension does not seem related to the recipient's pre-transplant blood pressure nor to the original renal disease. Rather, the high incidence of essential hypertension in the respective living related donor suggests that either a hypertensive diathesis exists, common to donor and recipient, or a transplantable factor inherent to the graft, or both causes, predispose to late onset primary hypertension.

Dialyzer-augmented whole blood and plasma exchange for patients with hepatic or hepatorenal failure.

We have utilized new methods of dialyzer-augmented whole blood and plasma exchange tranfusion in the treatment of hepatic coma. The method employs the new fast flow Buselmeier shunt so that the exchange can be done from a peripheral radial artery shunt site rather than a shunt site in a more major vessel, such as the brachial artery. The method employs in-line dialysis of citrated (CPD) blood or plasma to normalize pH, electrolytes, and blood sugar while infusion heparinization decreases heparin requirements. The application of a single roller pump to the administration and withdrawal lines (placed in opposite directions) helps equalize inflow and outflow where whole blood exchange is done while identical opposing pumps accomplish the same with plasma exchange. The administration of albumin and metaraminol bitartate prevents hypotension due to fluid shifts or compartmental venous dilatation. A closed circuit which does not require disconnection throughout the 30- 60-minute whole blood exchange or the 2 1/2-hour plasma exchange decreases the risk of septic contamination to both medical staff and patients.

Methionine-induced hepatic coma in dogs.

Oral methionine is noncomatogenic in normal dogs, but it is consistently comatogenic in dogs with portacaval shunts in the presence of elevated ammonia levels. Such action appears to be enhanced by the ammonia itself, since relatively small doses of oral methionine can induce coma when baseline levels of ammonia are above 1,000 mug/100 ml; much higher doses are nesessary for near normal ammonemia. The methionine-induced coma closely reproduces the clinical and electroencephalographic picture of coma in other canine models. Oral methionine does not significantly increase the ammonia levels, but its action is probably mediated by the release of methanethiol (and other less active compounds) from the bowel. Methanethiol levels tend to increase in proportion to the amount of methionine administered, and its comatogenic action may be amplified, up to one hundredfold, by high ammonia levels. Methanethiol levels in comatose patients and the concept of the synergistic effect with ammonia may lead to a clearer understanding of certain enterogenous and dietetic forms of hepatic encephalopathy in cirrhotic patients. The lowering of ammonia levels by hemodialysis or methanethiol levels by activated charcoal hemoperfusion, as attempts to reverse such forms of coma, warrants further investigation.

Postoperative chronic renal failure: a new syndrome?

Of 125 patients with postsurgical acute tubular necrosis, 87 died, 34 regained clinical normal renal function, and 4 survivors (9.5%) were left with severe permanent renal failure, two of whom required chronic dialysis and transplantation. Preoperatively these 4 patients had normal renal function. The 4 patients were above age 60, two had undergone methoxyflurane anesthesia, and nephrotoxic antibiotics were used in all. The incidence of permanent renal failure is much higher than ever reported and may reflect the survival of patients who previously died because of less ideal dialysis. We believe that the cause of this permanent lesion is multifactorial, including age (over 60 years), nephrotoxic antibiotics (particularly cephalothin and gentamicin sulfate), and nephrotoxic anesthetic (methoxyflurane) agents. This combination of factors should be avoided whenever possible.

Complications of percutaneous femoral vein catheterizations for hemodialysis.

Five life threatening complications of percutaneous femoral vein catheterization for hemodialysis (Shaldon Technique) are presented. They occurred over a period of five years during which 700 uneventful catheterizations were carried out. In three instances femoroiliac vein thrombosis occurred, and on one occasion this was complicated by pulmonary embolism. In two other instances perforation of the inferior vena cava occurred with profuse bleeding. These complications can be aboided by early removal of the catheters after dialysis and by cautiously manipulating the wireguide when resistance or obstruction is encountered during insertion.

Detection of canine kidney allograft rejection with 51Cr-labeled lymphocytes.

Mongrel dogs received transplanted kidneys following total nephrectomy. The whole blood was centrifuged to separate out the lymphocytic fraction, which was tagged with 51Cr. Renal accumulation of 51Cr was followed using imaging detectors. All allograft rejections were accompanied by a simultaneous rise in the count rate. Labeled lymphocytes can be used to detect canine renal rejection, and the authors feel that this technique can be applied to man.