Treatment of hemodialysis fistula pseudoaneurysms with detachable balloons: technique and preliminary results.

Pseudoaneurysm formation is commonly encountered during the life of a dialysis fistula. When these become excessively large or numerous, surgical revision of the graft has been the only treatment option. The authors have treated seven patients by using percutaneous placement of a detachable balloon to occlude a pseudoaneurysm of an upper extremity graft. In four cases the balloon was directed into the pseudoaneurysm from a femoral artery approach. In three cases a direct puncture was made into the pseudoaneurysm for placement of the balloon. The patients were followed up from 1 week to 7 months. Initial technical success was achieved in all seven cases with no complications. Thrombosis of two grafts occurred during the first week after the procedure: one because of herniation of the balloon out of the pseudoaneurysm and one for unknown reasons. One balloon was inadvertently punctured and deflated during subsequent dialysis. Treatment in the other four cases was successful, as evidenced by no further enlargement of the pseudoaneurysms. Direct puncture of the pseudoaneurysm simplifies the procedure and probably decreases the likelihood of balloon herniation because of the orientation of the balloon.

Cohort study of human immunodeficiency virus (HIV) antibody testing among patients receiving long-term dialysis at a university hospital.

In a longitudinal study to determine the seroprevalence of antibody to the human immunodeficiency virus (HIV) and the natural history of a positive enzyme immunoassay (EIA) result we followed a cohort of 98 patients receiving long-term dialysis. Eight patients (8.2%) in the cohort had a positive EIA and a negative Western blot test result. The EIA-positive results of all patients seroconverted to negative during follow-up. No illness suggestive of HIV infection developed in any of the patients. Significantly associated with a false positive EIA were prior renal transplantation, transfusions during the months just before the positive EIA result, and a greater number of lifetime transfusions before the positive test result. We confirm that routine HIV screening of patients receiving long-term dialysis is associated with a high rate of false positive EIA results and conclude that such testing is unnecessary in the absence of established risk factors for HIV infection.

Transient paralysis of upper extremity after percutaneous cannulation of the subclavian vein for hemodialysis.

Two cases of transient paralysis of upper extremity after percutaneous cannulation of the subclavian vein for hemodialysis are presented for the first time. Large amounts of lidocaine used, together with its deep and too lateral administration are responsible for development of this transient complication.

Treatment of gram-positive peritonitis with two intraperitoneal doses of vancomycin in continuous ambulatory peritoneal dialysis patients.

Eight patients with end-stage renal failure on continuous ambulatory peritoneal dialysis (CAPD), who developed peritonitis, received an intraperitoneal dose of vancomycin (30 mg/kg body weight) with 6 h of peritoneal dwell and then resumed their routine CAPD schedule. Vancomycin concentration in serum, peritoneal dialysate (PD) from an overnight dwell and 1, 2 and 3 h after a new exchange was measured at 48 h (in 5 patients) and 7 days (in 6 patients). Except for an occasional 1-hour peritoneal fluid sample on the 7th day, all samples had satisfactory vancomycin levels. Five of the 8 patients who had gram-positive peritonitis and 1 with 'sterile' peritonitis received another similar intraperitoneal dose of vancomycin at the 7th day. All of these patients had good therapeutic response with a negative PD culture 3 weeks after the cessation of therapy and no relapse of infection in at least 1 month of follow-up. We conclude that 2 intraperitoneal doses of vancomycin (30 mg/kg body weight) given 1 week apart with 6 h of intraperitoneal dwell is an effective and adequate treatment for gram-positive and 'sterile' peritonitis in CAPD patients.

Serum amylases in chronic and end-stage renal failure: effects of mode of therapy, race, diabetes and peritonitis.

Serum total amylase, pancreatic amylase and lipase activities were studied prospectively in 43 hemodialysis, 22 peritoneal dialysis and 22 chronic renal failure patients. None of the patients had symptoms of pancreatic disease at the time of study. Mean total amylase activities were similar and above the upper limit of normal in the 3 treatment groups. Total amylase was abnormal in 75% of the patients and exceeded twice the upper limit of normal in 24%. Blacks and nondiabetics had higher levels than whites and diabetic patients, respectively. Percentage pancreatic amylase exceeded the upper limits of normal in one third of the patients. Mean pancreatic amylase was above the upper normal limit in the 3 groups, and values were abnormal in 63% of all patients. Mean pancreatic amylase activity was significantly lower in peritoneal dialysis than in hemodialysis or chronic renal failure patients (p = 0.01). Pancreatic amylase activity was unaffected by race. The higher total amylase activity in blacks was due to increased salivary isoenzyme. Hemodialysis treatments did not change total amylase or pancreatic amylase activity. Mean lipase activity approximated the upper limit of normal in the 3 groups and values were abnormal in 42% of all patients. Serum total amylase and pancreatic amylase activity did not increase during episodes of peritonitis in the peritoneal dialysis group. Peritoneal dialysis, whether or not accompanied by peritonitis, was responsible for removal of only a small amount of amylase activity per day.(ABSTRACT TRUNCATED AT 250 WORDS)

Persistence of Candida despite seemingly adequate systemic and intraperitoneal amphotericin B treatment in a patient on CAPD.

A case of Candida peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD) is presented. Despite 2 weeks of intravenous and 4 weeks of intraperitoneal amphotericin B, good clinical response, and repeatedly negative fungal cultures from the peritoneal dialysate, her Tenckhoff catheter upon removal grew the same Candida species. This case emphasizes the point that Candida may persist on the catheter despite seemingly adequate antifungal treatment and good clinical and microbiologic response.

Cold lymphocytotoxins: an important cause of acute tubular necrosis occurring immediately after transplantation.

Cold-reactive lymphocytotoxins, present in some renal-transplant recipients, may be an important cause of the acute tubular necrosis (ATN) that commonly occurs immediately after transplantation. In a study of transplantation of optimally preserved cadaveric kidneys obtained from heart-beating donors, ATN was found in 10 of 17 recipients with cold antibodies and in only 1 of 21 recipients without such antibodies. Warming of the allograft after completion of anastomosis significantly reduced the incidence of ATN at 18% in recipients with cold antibodies. When pairs of reicpients with cold antibodies were transplanted with identically preserved cadaveric kidneys from single donors ATN was observed only in recipients whose donor kidney was not warmed. ATN may result from antibody-medicated damage to vascular endothelial cells during the brief period when the recipient's blood starts flowing into a "cold" allograft.

Prophylactic antibiotic therapy with cefamandole and tobramycin for patients undergoing renal transplantation.

The incidence of infections among patients undergoing renal transplantation has been reported as high as 83% during the first post-transplant year. In an effort to reduce the occurrence of such infections, we evaluated the role of perioperative prophylactic antibiotics in these patients. Thirty-seven patients undergoing transplantation were assigned randomly to treatment groups (N = 20, cefamandole, 1 gm IM every 6 hrs for 8 doses/tobramycin 1 mg/kg IM for 1 dose, starting 2 hrs prior to surgery) and control groups (N = 17, no antibiotics). A uniform infection surveillance system was used. Eighty-one percent (30/37) of patients became infected; 70% (14/20) of treated patients and 94% (16/17) of controls (p = 0.14). Since antibiotic prophylaxis might be expected to exert the greatest influence in the immediate postoperative period, we examined patient outcome data for both the first seven posttransplant days and for the entire hospitalization. Of the 38% (14/37) of patients who developed infections during the first posttransplant week, a statistically greater proportion came from the control group than from the treated group (10/17 vs. 4/20, p = 0.04). These data suggest that this regimen is effective in reducing the occurrence of infections during the first week following renal transplantation.

Primary oxalosis with livedo reticularis.

Livedo reticularis developed on the lower extremities of a 37-year-old woman with primary oxalosis and renal failure that was treated by hemodialysis. Biopsy results of the involved skin indicated oxalate crystals in the walls of the blood vessels of the dermis and subcutaneous tissue. Oxalosis with vascular involvement should be included in the long list of causes of livedo reticularis.

Comparison of alternate day steroids and daily steroids in renal transplant recipients.

This retrospective study examined whether alternate day steroid therapy decreased the incidence or severity of side effects of prednisone without decreasing renal function. We conclude that alternate day steroid therapy is indicated in adult renal transplant recipients to treat steroid-induced diabetes, hypertension and minor prednisone side effects, but is not useful for obesity. Further, alternate day steroid therapy can be used safely without compromising renal function or graft survival.

Kidney transplantation across positive B and T cell crossmatches.

Cadaveric renal transplants were performed despite a positive conventional crossmatch (usually intermediate positive) resulting from donor-specific B cell lymphocytotoxins (both IgG and IgM) or IgM cold-reactive T cell lymphocytotoxins. Graft survival at 2 months was 72% in the 14 patients with B cell-specific antibodies and 71% in the 7 recipients with T cell antibodies. No correlation was observed between graft rejection and warm (mainly IgG) or cold (IgM) B cell-specific antibodies. These results indicate that not all positive crossmatches are a contraindication to transplantation. Attempts should be made to study the nature of the lymphocytotoxins before withholding the allograft from the recipient.

Nephrotic syndrome and focal glomerular sclerosis in aging man.

Focal glomerular sclerosis (FGS) with the nephrotic syndrome is a disecades. Less than 2% of reported patients are older than 60 years of age, and to our knowledge no patients over 70 years of age have been described. The present report documents with renal biopsies the occurrence of FGS and the nephrotic syndrome in 4 patients with an average age of 70 years, 3 being septuagenarians. We suggest that FGS in these patients may represent a disease of senescence, and that FGS in younger patients may result from accelerated glomerulotubular senescence.

Use of hemodialysis in meprobamate overdosage.

A case of meprobamate overdosage successfully treated with hemodialysis is described. The patient was admitted 4 hours after an overdosage of meprobamate (30-40 g) deeply unconscious, hypotensive, in respiratory failure and with a serum meprobamate level of 50 mg/100 ml. Hemodialysis was instituted using a Gambro parallel flow dialyzer and a portable re-circulating dialyzate delivery system (Redy, CCi Life Systems). Meprobamate removal with hemodialysis was 672+/-167 mg/hr with a corresponding clearance of 61.97+/-9.9 ml/min. Drug removal with forced diuresis was 177+/-23.4 mg/hr. Metabolic degradation of the drug was approximately 482 mg/hr with a plasma disappearance rate of 5.2%/hr. No drug could be detected in the dialyzate fluid after its passage through the Redy re-circulating dialyzate system. Because of the rapidity of metabolic degradation of meprobamate, we feel that hemodialysis should be reserved for severe clinical intoxication and either compromised normal excretory routes or progressive clinical deterioration.

Therapy of the idiopathic nephrotic syndrome with alternate day steroids.

Eighty-one adult patients with the idiopathic nephrotic syndrome were treated with prednisone, 60 to 120 mg, on alternate days. Treatment was continued with diminishing drug doses for up to 10 years. Biopsy specimens were categorized as showing lipoid nephrosis 36 per cent, focal sclerosis 12 per cent, diffuse proliferative 22 per cent and membranous nephropathy 30 per cent. Patients with systemic causes of the nephrotic syndrome were excluded. Proteinuria decreased to normal or to less than or equal to 3 g with a greater than or equal to 50 per cent decrease from base line in 83 per cent of the patients with lipoid nephrosis, 30 per cent of the patients with focal sclerosis, 50 per cent of the patients with diffuse proliferative nephritis and 71 per cent of the patients with membranous nephropathy. Improvement occurred in those with focal sclerosis, diffuse proliferative nephritis and membranous nephropathy only after prolonged treatment (14 to 15 months). Stable or improved renal function occurred in 97 per cent of those with lipoid nephrosis, 50 per cent of those with focal sclerosis, 73 per cent of those with diffuse proliferative nephritis and in 83 per cent of those with membranous nephropathy. Death or dialysis occurred in 12 per cent of the patients, and complications coincident with treatment occurred once every 12 patient years. Compared to other series of patients with the idiopathic nephrotic syndrome, therapy of our patients with prolonged alternate day steroids resulted in (1) decreased protein excretion, (2) maintenance of good renal function and (3) decreased number of complications of therapy.

Utility of protease-digested human peripheral blood lymphocytes for the detection of lymphocyte-reactive alloantibodies by indirect immunofluorescence.

Human peripheral blood lymphocytes were digested briefly with protease prior to application of indirect immunofluorescence techniques for detecting alloantibodies in sera of patients with chronic renal failure on maintenance hemodialysis. Background staining of intrinsic surface IgM and cytophilic IgG bound to Fc receptors was eliminated or greatly reduced, enabling detection of B cell specific antibodies, including cold-reactive types not demonstrable by conventional immunofluorescence or complement-dependent lymphocytotoxicity. The antigenicity of HLA and other surface membrane determinants was not decreased by protease, although reactivity with certain sera was enhanced. In experiments comparing indirect immunofluorescence using protease-treated cells with complement-dependent lymphocytotoxicity and antibody-dependent, lymphocyte-mediated cytotoxicity assays, indirect immunofluorescence was more sensitive and comprehensive, but not less specific, in defining alloantibodies of a variety of types.