A prospective survey of patients presenting with abdominal aortic aneurysm.

OBJECTIVES: To define the presentation and management of patients presenting with abdominal aortic aneurysm (AAA) DESIGN AND SETTING: A prospective survey was carried out of all patients presenting to hospitals within the Oxford region. MATERIALS AND METHODS: Data were collected by one surgeon in each hospital. Full details were collected onto data sheets. RESULTS: One hundred and ninety patients presented, 141 electively, 46 with ruptured AAA and three with acute AAAs. In 53 patients presenting electively the aneurysm was small and surveillance started. Fifty-six patients underwent an operation, three patients died. Of 46 patients with a ruptured aneurysm 24 (52%) died. In 11 no operation was carried out and all of these patients died within 24 h. Operative mortality was 13 of 35 patients (37%). More patients with a ruptured AAA were transferred to the teaching hospital compared with a district general hospital (p < 0.05). This was reflected in a lower operative mortality in the teaching hospital. CONCLUSIONS: The presentation of AAA in this study was approximately 15 per 100,000 population. Approximately one-third of patients presenting electively had small AAAs which required surveillance. A further third underwent an operation, the remaining patients being unfit. Approximately one-quarter of patients with a ruptured aneurysm did not undergo an operation. The operative mortality was 37%.

Rehabilitation outcome 5 years after 100 lower-limb amputations.

Received wisdom commends a policy of maximizing the ratio of below-knee to above-knee amputations in patients with end-stage arterial disease. After adoption of this policy, the long-term outcome of 100 consecutive lower-limb amputations in 96 patients was monitored by annual review for 5 years. The ratio of primary below-knee to above-knee amputations was 2:1, with 9 per cent of below-knee amputations undergoing revision to a higher level. At 2 years after amputation only 26 per cent of patients were successfully walking out of doors, while 40 per cent had died. By 5 years 67 per cent were dead and only 9 per cent continued to walk out of doors with an artificial limb, although a further 8 per cent continued to use the limb within the confines of their own homes. In a previous audit of 193 amputations performed during the 3.5 years to December 1984, stump healing was a problem in 45 per cent of primary below-knee amputations, compared with 25 per cent in the present study. Although the below- to above-knee ratio in 1984 was only 1:2, the overall rehabilitation rate, as determined by the proportion of patients able to walk at 2 years, was 34 per cent. It is concluded that increasing the proportion of below-knee amputations from one-third to two-thirds of lower-limb amputations for occlusive arterial disease does not improve effective rehabilitation rates. Received wisdom on the desirability of a high below- to above-knee ratio may be wrong.

Provision of vascular surgical services in the Oxford Region.

Vascular surgical practice across an entire health region was studied. There was a mean of 115.9 inpatient episodes and 46.9 vascular reconstructions per 100,000 population, with considerable variation between districts. Vein utilization for infrainguinal grafts was greater in the teaching hospital and few femorodistal grafts or carotid endarterectomies were carried out elsewhere; there were few tertiary referrals of elective vascular cases. Only two districts have formal arrangements for emergency vascular 'on-call'. There is marked inequality of provision of vascular surgical services across the region.

Combination drug therapies for immunosuppression in transplantation.

Current combination immunosuppression protocols used worldwide include azathioprine/prednisolone, cyclosporine protocols, cyclophosphamide/steroids and FK506/steroids. The fact that many different immunosuppression protocols are currently in use, demonstrates that none is ideal. Major determinants in the choice of any protocol include graft and patient survival, side effects and cost. While most protocols may offer one year graft survival rates of 80% to 90% in renal transplantation, it is the long term results which are becoming increasingly important, but as many protocols have only been recently introduced, it may be sometime before these answers are known. While the most effective regimens include cyclosporine, long term nephrotoxicity remains a problem. Furthermore, the cost of the drug may be prohibitive in many countries worldwide. Azathioprine and low dose steroids still provide acceptable results with lesser expense and where cost and drug availability are critical, cyclophosphamide may even be introduced in place of azathioprine in living-related renal transplant recipients. The role of the newer immunosuppressive agents such as FK506 remains unclear, as the results of prospective randomised studies are not yet available. With excellent results now obtained with many different protocols, it is apparent that the choice of the most suitable immunosuppressive regimen is no longer dictated by graft survival alone.

Immunohistological analysis of renal allograft biopsies from cyclosporin-treated patients. Induced HLA-class II antigen expression does not exclude a diagnosis of cyclosporin nephrotoxicity.

Differentiation of cyclosporin nephrotoxicity from renal allograft rejection is often difficult. Induction of tubular HLA-class II antigens and elevated levels of leucocyte infiltration are associated with allograft rejection but their association with cyclosporin nephrotoxicity is unclear. In order to determine these relationships, transplant biopsies (n = 32) from patients considered to have cyclosporin nephrotoxicity, allograft rejection or stable graft function were stained with monoclonal antibodies specific for HLA-class II antigens and infiltrating leucocytes. Leucocyte infiltration was elevated during rejection but not in cyclosporin nephrotoxicity or stable graft function. While HLA-class II antigen expression was induced in 71% of the biopsies obtained during clinical rejection, no increased expression was found in the other 29%. Induced antigens were detected in five of the nine biopsies obtained in the presence of cyclosporin nephrotoxicity 90 days after transplantation. In four of these, induction was attributed to prolongation of increased class II expression following previous rejection episodes. Thus, the presence of induced class II antigens in the renal allograft does not exclude a diagnosis of cyclosporin nephrotoxicity.

The diagnosis of renal allograft rejection: an improved assessment of graft infiltration using image analysis.

These results show that image analysis is an accurate alternative to point counting in the assessment of infiltration in renal allograft biopsies and can provide an efficient and rapid diagnosis of cellular rejection in the transplanted patient.

Precise specificity of induced tubular HLA-class II antigens in renal allografts.

HLA-class II antigen expression is induced in the tubules of renal allografts, but it is unclear whether all three class II products--HLA-DR, DQ, and DP--are induced, and whether the induced product is of donor origin. A pretransplant (n = 14) and serial transplant biopsies (n = 45) were obtained from 14 transplant recipients in whom induced HLA-class II antigen was detected after transplantation with a monoclonal antibody reactive with HLA-DR, DP, and possibly DQ antigens. Cryostat sections were stained with locus-specific or polymorphic monoclonal antibodies in an indirect immunoperoxidase assay. In pretransplant biopsies intracellular HLA-DR antigen was expressed on proximal tubules, whereas all tubules were negative for HLA-DQ and DP products. After transplantation grafts with induced tubular HLA-class II antigen had induced HLA-DR, DQ and DP antigens expressed both within the cytoplasm and on the cell membranes. The donor or recipient origin of induced HLA-class II expression was determined using polymorphic antibodies specific for either donor or recipient antigens. This approach demonstrated that the induced class II antigen is of donor origin--and, furthermore, that the renal parenchyma remains of donor HLA-type, even one year after transplantation, and thus remains a source of antigenic stimulus to the recipient.

The influence of HLA-A,B and -DR matching on leucocyte infiltration in renal allografts.

The influence of donor and recipient HLA-A,B and -DR matching on the cellular infiltration in renal allografts was examined in 78 transplant recipients who received either cyclosporin (Cy) or azathioprine and low-dose prednisolone (AP) immunosuppression. Transplant biopsies (n = 161) were routinely obtained up to 40 days after transplantation, and biopsy material was therefore available from both rejecting grafts and grafts with stable function. Tissue sections were labelled with a panel of monoclonal antibodies and stained using an indirect immunoperoxidase technique. Cellular infiltration was assessed using a morphometric point counting technique. In AP-treated patients with well-functioning grafts, poor HLA-AB and HLA-DR matching was associated with increased leucocyte infiltration, while in patients receiving Cy therapy the effect of matching on cellular infiltration was seen only during rejection in grafts poorly matched for HLA-AB antigens. In addition, where an effect of HLA-AB matching on cellular infiltration was found, CD8+, but not CD4+ cells, were significantly increased in number, while when an HLA-DR matching effect was seen, a significant increase was observed in the CD4+ and not the CD8+ infiltration. Thus, HLA matching may influence the magnitude of the cellular response in renal allografts and the phenotype of the infiltrating cells.