The impact of bleeding times on major complication rates after percutaneous real-time ultrasound-guided renal biopsies.

BACKGROUND: Previous studies have shown that bleeding times have positive predictive values of only 5% for perioperative bleeding in unselected populations. Nevertheless, performing bleeding times prior to all renal biopsies is common in nephrology practice. METHODS: We report complications of 112 renal biopsies done at Walter Reed Army Medical Center (WRAMC) from 1996-99 performed without preceding bleeding times. Renal biopsies were done only on normotensive (<140/90) patients who had not recently been taking aspirin or non-steroidal anti-inflammatory agents, under real-time ultrasound guidance with automated 16 g (WRAMC) spring-loaded guns. High-risk patients (with serum creatinine > or = 3 mg/dl or creatinine clearance < or =30 cc/min by Cockroft-Gault formula, N=18, 16%) at WRAMC were treated with pre-renal biopsy estrogens or DDAVP. Factors were tested for their association with complications after renal biopsy using Chi Square testing for categorical variables and student's t-test for continuous variables. A stepwise logistic regression model was used to test for independent significance of factors. RESULTS: There were two cases each of gross hematuria and inadequate tissue (1.8% each). There were no transfusions or deaths. In univariate analysis, male gender and lower serum creatinine level at time of biopsy were significantly associated with increased risk of complications after biopsy. However, these factors were not significant in logistic regression analysis. CONCLUSION: This study suggests that the use of bleeding times does not significantly alter the major complication rates associated with percutaneous real-time ultrasound guided renal biopsy.

Transplantation in the military: state of the art--a progress report from the Army-Navy Transplant Program.

The commitment to clinical transplantation services by the Army and Navy is now in its third decade. Located at the Walter Reed Army Medical Center, the Army-Navy Organ Transplant Service has been staffed and led by some of the most prominent transplant surgeons in America. Military beneficiaries are eligible for evaluation and care regardless of their geographic assignment or residence. Principally a renal transplant clinical service, the Organ Transplant Service also gives support to patients with heart, liver, and pancreas grafts. Organs for transplant are largely (85%) from the civilian sector, although the Department of Defense has officially encouraged organ donation. Research, scientific publication, protocol development, teaching, and interaction with reserve components have been major facets of the Organ Transplant Service. Clinical outcome in renal transplantation at the Army-Navy Unit is comparable to that at the best civilian units: 2-year graft and patient survival 81% and 98%, respectively. These superior clinical results and the major roles that the Army-Navy Transplant Service have played make continued support and expansion of military transplantation compelling.

Experiences with cadaver renal allograft contamination before transplantation.

Microbial contamination occurred in 23 (13 per cent) of 177 cadaver donor kidneys prior to renal transplantation. In 16 cases there were no complications directly attributable to the organisms recovered from the preservation media. Three patients developed perinephric infections associated with renal artery anastomotic disruption and required emergency transplant nephrectomy. A fourth patient developed renal artery stenosis and a hypogastric artery aneurysm that required correction 6 months later with preservation of renal allograft function. In 3 cases no follow-up information was available. None of the 154 uncontaminated kidneys developed arterial disruption or aneurysm. Candida albicans and Pseudomonas aeruginosa infections were responsible for the nearly disastrous arterial disruptions and possibly the hypogastric arterial aneurysm. These findings demonstrate the importance of bacteriological surveillance of perfusion media to detect nosocomial infection, to guide antibiotic chemotherapy and to direct surgical management of septic complications. In our experience contamination was not necessarily incompatible with long term satisfactory results; however, when complications did occur they were serious. It is likely that the size of the microbial inoculum, the patient's immune competence and the protective effect of antibiotic therapy administered to the donor and recipient affected the eventual outcome.

Fresh versus stored blood in donor specific transfusion.

Haploidentical, MLC responsive recipients were randomized to receive either fresh (less than 48 hours old) or stored donor specific transfusions (DST). In the stored DST group, one donor unit obtained with CPD-Adenine anticoagulant was split into three aliquots and administered as packed cells after 1, 3, and 5 weeks of storage. While 3/6 fresh DST recipients became sensitized to their donors, 0/12 receiving stored DSTs developed positive donor crossmatches. Eleven patients (three fresh, eight stored) have been transplanted and have had similar posttransplant courses. None of the stored DST recipients has rejected his transplant. Four recipients of stored DSTs are awaiting transplantation. Leukocyte enumeration and FACS analysis of aliquots of stored blood shown that cells bearing HLA-ABC antigens disappear with time while B cells and monocytes persist. Taken in concert, the observations suggest that favorable recipient conditioning for transplantation can take place without sensitization to HLA antigens by simply storing the blood prior to transfusion.