Reduced racial disparities among newborns with intraventricular hemorrhage

INTRODUCTION

Intraventricular hemorrhage (IVH) can ensue permanent neurologic dysfunction, morbidity, and mortality. While previous reports have identified disparities based on patient gender or weight, no prior study has assessed how race may influence in neonatal or infantile IVH patients. The aim of this study was to investigate the impact of race on adverse event (AE) rates, length of stay (LOS), and total cost of admission among newborns with IVH.

METHODS

Using the 2016-2019 National Inpatient Sample database, newborns diagnosed with IVH were identified using ICD-10-CM codes. Patients were stratified based on race. Patient characteristics and inpatient outcomes were assessed. Multivariate logistic regression analyses were used to identify the impact of race on extended LOS and exorbitant cost.

RESULTS

Of 1435 patients, 650 were White (45.3%), 270 African American (AA) (18.8%), 300 Hispanic (20.9%), and 215 Other (15.0%). A higher percentage of AA and Other patients than Hispanic and White patients were < 28 days old (p = 0.008). Each of the cohorts had largely similar presenting comorbidities and symptoms, although AA patients did have significantly higher rates of NEC (p < 0.001). There were no observed differences in rates of AEs, rates of mortality, mean LOS, or mean total cost of admission. Similarly, on multivariate analysis, no race was identified as a significant independent predictor of extended LOS or exorbitant cost.

CONCLUSIONS

Our study found that in newborns with IVH, race is not associated with proxies of poor healthcare outcomes like prolonged LOS or excessive cost. Further studies are needed to validate these findings.

Kidney allocation to liver transplant candidates with renal failure of undetermined etiology: role of percutaneous renal biopsy

The feasibility, value and risk of percutaneous renal biopsy (PRB) in liver transplant candidates with renal failure are unknown. PRB was performed on 44 liver transplant candidates with renal failure of undetermined etiology and glomerular filtration rate (GFR) <40 mL/min/1.73 m(2) (n = 37) or on renal replacement therapy (RRT) (n = 7). Patients with >or=30% interstitial fibrosis (IF), >or=40% global glomerulosclerosis (gGS) and/or diffuse glomerulonephritis were approved for simultaneous-liver-kidney (SLK) transplantation. Prebiopsy GFR, urinary sodium indices, dependency on RRT and kidney size were comparable between 27 liver-transplant-alone (LTA) and 17 SLK candidates and did not relate to the biopsy diagnosis. The interobserver agreement for the degree of IF or gGS was moderate-to-excellent. After a mean of 78 +/- 67 days, 16 and 8 patients received LTA and SLK transplants. All five LTA recipients on RRT recovered kidney function after transplantation and serum creatinine was comparable between LTA and SLK recipients at last follow-up. Biopsy complications developed in 13, of these, five required intervention. PRB is feasible in liver transplant candidates with renal failure and provides reproducible histological information that does not relate to the pretransplant clinical data. Randomized studies are needed to determine if PRB can direct kidney allocation in this challenging group of liver transplant candidates.

Continued influence of preoperative renal function on outcome of orthotopic liver transplant (OLTX) in the US: where will MELD lead us?

Renal function is a component of the Model for End Stage Liver Disease (MELD), We queried the 1999-2004 OPTN/UNOS database to determine whether preoperative renal function remained an important determinant of survival in primary deceased donor liver transplant alone patients (DDLTA) or primary combined kidney liver transplant patients (KLTX). We examined preoperative creatinine, renal replacement therapy (RRT), incidence of KLTX, and patient survival in the 34 months before and after introduction of MELD and performed a multivariate Cox regression analysis of time to death. Preoperative renal function is an independent predictor of survival in DDLTA but not in KLTX. When compared to DDLTA with a preoperative serum creatinine of 0-0.99 mg/dL, patients with serum creatinine from 1-1.99 mg/dL, >2.0 mg/dL, those requiring RRT, and those receiving KLTX had a relative risk of death following transplant of 1.11, 1.58, 1.77, and 1.44 respectively. KLTX requiring RRT had better survival than DDLTA requiring RRT. Since introduction of MELD, KLTX, preoperative creatinine, and number of patients requiring preoperative RRT have increased. Despite this, patient survival following orthotopic liver transplant (OLTX) in the 34 months after introduction of MELD is not different than prior to introduction of MELD.

Genetic basis of heterosis and inbreeding depression in rice (Oryza sativa L.)

The genetic basis of heterosis was studied through mid-parent, standard variety and better parent for 11 quantitative traits in 17 parental lines and their 10 selected hybrids in rice (Oryza sativa L.). The characters were plant height, days to flag leaf initiation, days to first panicle initiation, days to 100% flowering, panicle length, flag leaf length, days to maturity, number of fertile spikelet/panicle, number of effective tillers/hill, grain yield/10-hill, and 1000-grain weight. In general the hybrids performed significantly better than the respective parents. Significant heterosis was observed for most of the studied characters. Among the 10 hybrids, four hybrids viz., 17Ax45R, 25Ax37R, 27Ax39R, 31Ax47R, and 35Ax47R showed highest heterosis in 10-hill grain yield/10-hill. Inbreeding depression of F2 progeny was also studied for 11 characters of 10 hybrids. Both positive and negative inbreeding depression were found in many crosses for the studied characters, but none was found significant. Selection of good parents was found to be the most important for developing high yielding hybrid rice varieties.

Induction immunotherapy with IL-2Ra monoclonal antibody in kidney transplantation

The development of new immunosuppressive agents is designed to reduce the incidence and severity of early acute post-transplant rejection. One potential target for more specific immunosuppressive therapy with monoclonal antibodies is the high affinity a chain of interleukin-2 receptors (IL-2Ra). Clinical investigation of murine IL-2Ra monoclonal antibodies (IL-2Ra mAb) in renal transplantation has indicated that a complete blockade of IL-2Ra during the critical first post-transplant months allows effective immunoprophylaxis, especially in the early post-transplant period. Efficacy of these agents, however, is hampered by their short disposition half-lives in humans and their immunogenicity in the form of neutralizing human antimouse antibodies. These inherent problems can be partially overcome by chi-meric, hyper-chimeric (humanized) products and multiple dose regimens. Both IL-2Ra mAbs: daclizumab (humanized) and basiliximab (chimeric) currently approved for clinical use have been found to reduce the frequency of acute rejections in renal transplant recipients without an apparent increase in short-term toxicities. In most transplant centers where these agents are utilized, they are being routinely administered as induction immunoprophylaxis in recommended multiple dose regimens to recipients of solid organ transplants. Others have restricted their use to certain high-risk patients such as those undergoing multi-organ transplantation, recipients with high panel-reactive antibodies, African-Americans, patients at risk for developing delayed graft function (DGF), and children. Recently some investigators have successfully administered these antibodies co-administered with newer immunosuppressive agents in limited dose protocols thus developing cost effective and simplified regimens. Therefore, in the absence of a favorable long-term efficacy, it is likely that these agents will be administered in limited dose protocols along with one of the modulators of IL-2, i.e. calcineurin inhibitors (CNI), to a selected group of patients in whom additional immunosuppression in the early post-transplantation period is desirable.

Lipid formulations of polyene antifungal drugs and attenuation of associated nephrotoxicity

Amphotericin B is an effective broad-spectrum antifungal agent, but various side effects, especially nephrotoxicity, have restricted its use. Recently, lipid formulations of amphotericin B have been developed in order to reduce its toxic side effects. Clinical trials, although in the early stages, suggest promising results, and that some of these lipid formulations are potent and less toxic, even at higher doses. We summarize herein the existing information about newer lipid formulations of polyene antifungal drugs, which could attenuate associated nephrotoxicity.

Myoglobinuria: evaluation of methods in the clinical diagnosis acute renal failure

Patients with red--brown urine which may be a sign of myoglobinuria, can develop acute renal failure. We assayed serum creatinine, blood urea nitrogen (BUN) and creatine kinase activity in a total of 33 patients of equal groups, A (automobile accident), B (trauma) and C (undergoing rhabdomyolysis). In addition we tested 132 urine samples for the presence of myoglobin using a dipstick assay. Only five patients in group A showed any sign of myoglobinuria with increased creatine kinase activity upto 7 times the normal value but their serum creatinine level and BUN were within the normal range. In contrast, all 22 patients in group B and C showed myoglobinuria and above normal concentrations of serum creatinine and BUN, with significantly increased (p < 0.0001) creatine kinase activity upto 150 times the normal range. Four of the most seriously ill patients in group C developed acute renal failure. Supplementation of routine determinations of serum creatinine and BUN and serum creatine kinase activity with a rapid test for myoglobinuria provides an extra indication of impending renal dysfunction. It may be beneficial in the emergency management of these patients.

Randomized trial of tacrolimus plus mycophenolate mofetil or azathioprine versus cyclosporine oral solution (modified) plus mycophenolate mofetil after cadaveric kidney transplantation: results at 2 years

BACKGROUND

A previous report described the 1-year results of a prospective, randomized trial designed to investigate the optimal combination of immunosuppressants in kidney transplantation. Recipients of first cadaveric kidney allografts were treated with tacrolimus+mycophenolate mofetil (MMF), cyclosporine oral solution (modified) (CsA)+MMF, or tacrolimus+azathioprine (AZA). Results at 1 year revealed that optimal efficacy and safety were achieved with a regimen containing tacrolimus+MMF. The present report describes results at 2 years.

METHODS

Two hundred twenty-three recipients of first cadaveric kidney allografts were randomized to receive tacrolimus+MMF, CsA+MMF, or tacrolimus+AZA. All regimens contained corticosteroids, and antibody induction was used only in patients who experienced delayed graft function. Patients were followed up for 2 years.

RESULTS

The results at 2 years corroborate and extend the findings of the previous report. Patients randomized to either treatment arm containing tacrolimus experienced improved kidney function. New-onset insulin dependence remained in four, three, and four patients in the tacrolimus+MMF, CsA+MMF, and tacrolimus+AZA treatment arms, respectively. Furthermore, patients with delayed graft function/acute tubular necrosis who were treated with tacrolimus+MMF experienced a 23% increase in allograft survival compared with patients receiving CsA+MMF (P=0.06). Patients randomized to tacrolimus+MMF received significantly lower doses of MMF compared with those administered CsA+MMF.

CONCLUSIONS

All three immunosuppressive regi-mens provided excellent safety and efficacy. How-ever, the best results overall were achieved with tacrolimus+MMF. The combination may provide particular benefit to kidney allograft recipients who develop delayed graft function/acute tubular necrosis. Renal function at 2 years was better in the tacrolimus treatment groups compared with the CsA group.

Infusion of total dose iron versus oral iron supplementation in ambulatory peritoneal dialysis patients: a prospective, cross-over trial

The efficacy of intermittent, small doses of intravenous iron in hemodialysis patients is well established. But poor peripheral vascular access and frequency of therapy preclude acceptability of this method in peritoneal dialysis (PD) patients. Therefore, despite its marginal efficacy, oral iron remains the common method of iron supplementation in these patients. This prospective, cross-over trial compares infusion of total dose iron (ITDI) and oral iron supplementation in outpatient PD patients. Eleven stable CAPD patients with an hematocrit (Hct) of less than 33%, or a transferrin saturation (TSAT) of less than 30%, or both, were entered into the study. The study design included an oral phase [4 months, ferrous sulfate 325 mg (195 mg elemental iron), three times daily], a "wash-out" phase (1 month, no iron supplementation), and an ITDI phase [4 months, single infusion over 4 hours of 1 g iron dextran mixed in 1/2 normal saline]. Laboratory parameters were monitored monthly, and subcutaneous recombinant human erythropoietin (rHuEPO) doses were adjusted monthly to maintain a hematocrit above 33%. Patients with hyperparathyroidism, aluminum toxicity, and weekly Kt/V below 1.8 were excluded. Nine patients [8 Caucasians, 1 African American; causes of end-stage renal disease (ESRD): hypertension (4 cases), diabetes (3 cases), glomerulonephritis (1 case), and polycystic kidney disease (1 case); mean age: 43.3 +/- 2 years; mean weight: 73.0 +/- 4 kg; duration of ESRD: 28 +/- 13 months] completed the 9-month study. During the oral phase, TSAT rapidly decreased and a higher dose of rHuEPO failed to maintain Hct, a pattern sustained during the "wash-out" phase. During the ITDI phase, TSAT significantly increased and improvement in Hct resulted in a significant lowering of rHuEPO doses. The ITDI therapy was well tolerated. We conclude that ITDI is the preferred method of iron supplementation in outpatient PD patients.

Heat shock protein 47 in renal scarring

Heat shock protein 47 (HSP47) is a collagen-binding protein, thought to play an essential mechanistic role in the assembly and processing of procollagens. HSP47 is increasingly being implicated in the pathogenesis of several human and experimental fibrotic diseases. HSP47 could mediate increased accumulation of collagens in the fibrotic mass, possibly by regulating increased assembly of procollagens. Therefore, modulation of HSP47 might be a valuable tool for manipulation of some fibrotic diseases, including renal scarring

Expression of angiotensin II type I receptor on erythroid progenitors of patients with post transplant erythrocytosis

BACKGROUND

The pathogenesis of posttransplant erythrocytosis (PTE) has been elusive. Angiotensin converting enzyme inhibitors (ACEI) are efficacious in lowering the hematocrit of patients with PTE and angiotensin II (AII) type I receptors (AT1R) were recently detected on red blood cell precursors, burst-forming unit-erythroid- (BFU-E) derived cells. The purpose of this study was to determine whether there is increased expression of the AT1R on BFU-E-derived cells of patients with PTE, which might contribute to the pathogenesis of PTE.

METHODS

Twelve healthy volunteers and 25 transplant recipients (13 patients with and 12 without PTE) were studied. BFU-E from peripheral blood were cultured in methylcellulose and BFU-E-derived colonies were harvested on day 10. Western blotting was used to detect AT1R and erythropoietin receptor (EpoR) expression. Intracellular free calcium in response to AII and erythropoietin (Epo) was measured with digital video imaging.

RESULTS

There were no differences between transplant patients, with and without PTE, with respect to weight, age, sex, blood pressure, serum creatinine, circulating renin, angiotensin II, and Epo levels. Hematocrit, red blood cell number, BFU-E-derived colony number,and size were significantly increased in PTE compared with other two groups. AT1R expression was increased by 44% on the erythroid progenitors of PTE versus non posttransplant erythrocytosis patients and by 32% in PTE patients versus normal volunteers. AT1R expression correlated significantly with the hematocrit in PTE (Spearman r=0.68, P=0.01). In contrast, EpoR expression was equivalent in all groups. The AT1R was functional since a significant increase in [Ca(i)] was observed in Fura-2 loaded day 10 cells when stimulated with AII (182%, P<0.0001).

CONCLUSION

An increase in AT1R density was observed in erythroid precursors of transplant patients with PTE compared to those without PTE and normal volunteers, and the level of AT1R expression in PTE correlated significantly with the hematocrit. In contrast, EpoR expression was not different in PTE compared with non posttransplant erythrocytosis or normal controls. This study supports a role for the AT1 receptor signaling pathway in the pathogenesis of PTE.

Laparoscopic-assisted renal biopsy: an alternative to open approach

An open renal biopsy frequently is performed when the conventional percutaneous approach is contraindicated. Although many of the surgical procedures, previously performed by a traditional open technique, are now successfully accomplished by laparoscopic technique, there remains a paucity of reports on laparoscopic kidney biopsy. We describe the use of laparoscopic technique in performing native kidney biopsy in three patients and review the potential safety and accuracy of this approach. To date, laparoscopic-assisted renal biopsy has been reported in six patients. The average length of stay in our small series was 1.3 days, and there were no major or catastrophic complications. Adequate numbers of glomeruli for confirmation of microscopic diagnosis were obtained in all cases. The review of literature, in addition to our encouraging preliminary results of a small group of patients, shows a possible role of laparoscopic-assisted renal biopsy in place of an open renal biopsy.

In vivo and in vitro modulation of immune stimulatory capacity of primary dendritic cells by adenovirus-mediated gene transduction

Dendritic cells (DCs) are potent antigen-presenting cells which are key leukocytes in the initiation of cell-mediated organ graft rejection, antiviral immunity, and antitumor responses. In this study we demonstrate that genetic modification of primary human and mouse DCs by adenoviral gene transfer is an effective means of induction and modulation of antigen presentation by DCs. An adenovirus vector (AdLacZ) was used to express an intracellular model antigen beta-galactosidase (beta-gal) in DCs. Our results show that 30-40% of precursor dendritic cells (PDCs) derived from human umbilical cord blood and circulating mature blood DCs express high levels beta-galactosidase (beta-gal) after infection with AdLacZ with no cytopathic effect observed. In vitro, AdLacZ transduced PDCs and DCs demonstrated a 10- to 20-fold higher mixed lymphocyte reaction (MLR) stimulatory capacity as compared to that of monocytes. In vivo, immunization with AdLacZ transduced mouse DCs resulted in more potent cytotoxic T lymphocyte (CTL) responses against the predicted H-2 restricted beta-gal epitope as compared to CTL responses obtained by beta-gal peptide pulsed DCs. Modulations of the MLR stimulatory capacity of DCs were examined by expression of mouse B7 and CTLA-4Ig. The results show that expression of mouse B7 by a recombinant adenoviral vector (Ad7) significantly enhances the MLR stimulatory capacity of human DCs. In contrast, expression of CTLA-4Ig (AdCTLA-4Ig) reduces the MLR stimulatory capacity of the transduced cells. We conclude that recombinant adenovirus can readily be used for genetic modulation DC-induced immune responses in vivo and in vitro. DCs targeted for induction of specific antigen responses or for modulation of the immune stimulatory capacity may have a potential use in the control of transplantation rejection or viral infections.

Randomized trial of tacrolimus (Prograf) in combination with azathioprine or mycophenolate mofetil versus cyclosporine (Neoral) with mycophenolate mofetil after cadaveric kidney transplantation

BACKGROUND

Our clinical trial was designed to investigate the optimal combination of immunosuppressants for renal transplantation.

METHODS

A randomized three-arm, parallel group, open label, prospective study was performed at 15 North American centers to compare three immunosuppressive regimens: tacrolimus + azathioprine (AZA) versus cyclosporine (Neoral) + mycophenolate mofetil (MMF) versus tacrolimus + MMF. All patients were first cadaveric kidney transplants receiving the same maintenance corticosteroid regimen. Only patients with delayed graft function (32%) received antilymphocyte induction. A total of 223 patients were randomized, transplanted, and followed for 1 year.

RESULTS

There were no significant differences in baseline demography between the three treatment groups. At 1 year the results are as follows: acute rejection 17% (95% confidence interval 9%, 26%) in tacrolimus + AZA; 20% (confidence interval 11%, 29%) in cyclosporine + MMF; and 15% (confidence interval 7%, 24%) in tacrolimus + MMF. The incidence of steroid resistant rejection requiring antilymphocyte therapy was 12% in the tacrolimus + AZA group, 11% in the cyclosporine + MMF group, and 4% in the tacrolimus + MMF group. There were no significant differences in overall patient or graft survival. Tacrolimus-treated patients had a lower incidence of hyperlipidemia through 6 months posttransplant. The incidence of posttransplant diabetes mellitus requiring insulin was 14% in the tacrolimus + AZA group, 7% in the cyclosporine + MMF and 7% in the tacrolimus + MMF groups.

CONCLUSIONS

All regimens yielded similar acute rejection rates and graft survival, but the tacrolimus + MMF regimen was associated with the lowest rate of steroid resistant rejection requiring antilymphocyte therapy.

ITDI is the preferred treatment for iron supplementation in rHuEpo-treated anemic PD patients

In recombinant human erythropoietin (rHuEpo)-treated anemic peritoneal dialysis (PD) patients, oral iron therapy, despite its limited efficacy, remains an accepted and convenient method of iron supplementation. In this study, we compared infusion of total dose iron (ITDI) to oral iron for the treatment of anemia in PD patients. Thirteen patients with serum transferrin saturation (TSAT) < 25% received ITDI and 11 patients with TSAT between 25% to 35% received oral iron. Doses of rHuEpo were adjusted monthly to maintain target hematocrit at 35%. Both groups had similar baseline mean hematocrits (31.0 +/- 0.9% vs. 33.0 +/- 1.0%), and comparable mean baseline weekly rHuEpo dose (7886 +/- 1449 units/week vs. 6370 +/- 1553 units/week). At the end of the 6-month study, the ITDI group had a 16% improvement in mean hematocrit compared to baseline. The final mean dose of weekly rHuEpo was also reduced by 59% in the ITDI group. During the same period, compared to baseline, the oral group had a 4.8% fall in mean hematocrit despite 51% higher requirement of rHuEpo doses. There was no adverse reaction to intravenous iron. We conclude that ITDI is the preferred treatment for iron supplementation in rHuEpo-treated anemic PD patients.

Prednisone withdrawal in kidney transplant recipients on cyclosporine and mycophenolate mofetil--a prospective randomized study. Steroid Withdrawal Study Group

BACKGROUND

Prospective randomized trials have shown a reduced rate of acute rejection (AR) in mycophenolate mofetil-treated kidney transplant recipients. We hypothesized that this increased protection from AR could allow successful prednisone (P) withdrawal in cyclosporine/mycophenolate mofetil/P-treated recipients.

METHODS

A multicenter, prospective, randomized, double-blind trial of P withdrawal at 3 months post-transplant was initiated. Entry criteria were: primary transplant, adult, no AR by 90 days, mycophenolate mofetil dose > or =2 g/day, cyclosporine dose = 5-15 mg/kg/ day, P dose = 10-15 mg/day. Study participants were randomized to have P tapered over 8 weeks (beginning at 3 months posttransplant) to 0 vs. 10 mg/day. Prestudy power analysis determined 500 recipients should be randomized for 80% statistical power to test equivalence of the primary endpoint, AR, or treatment failure at 1 year posttransplant. By design, the study was to be stopped if interim data precluded reaching equivalence. An established data safety monitoring board monitored the study.

RESULTS

After 266 patients were enrolled, the patient enrollment was stopped (after safety monitoring board review) because of excess rejection in the P withdrawal group. The Kaplan-Meier estimate of the cumulative incidence of rejection or treatment failure within 1 year posttransplant (+/-95% confidence interval) for the maintenance group was 9.8% (4.4%; treatment failure, 14.9%); for the withdrawal group, 30.8% (21.0%; 39.3%). Treatment differences in the distribution of time to event were highly significant (P = 0.0007). Of note, risk was higher in blacks (39.6%) versus nonblacks (16.0%) (P<0.001). At 1 year post-transplant, there was no difference between groups in patient or graft survival. For the patients with functioning grafts at 6 months posttransplant, withdrawal patients had lower cholesterol (P = 0.0005), had higher creatinine (P = 0.03), and were less likely to use antihypertensives (P = 0.001). These differences persist to 1 yr posttransplant.

CONCLUSIONS

We conclude that for recipients on cyclosporine/mycophenolate mofetil/P with no AR at 90 days, the chance of developing subsequent AR is small; if P is tapered and withdrawn, the risk increases (but the majority remain free of acute and chronic rejection). After withdrawal, the risk of AR is different for blacks versus nonblacks. Withdrawal patients had a lower cholesterol level and less need for antihypertensives.

New strategies using 'low-dose' mycophenolate mofetil to reduce acute rejection in patients following kidney transplantation

CONTEXT

Tacrolimus, microemulsion cyclosporine (Neoral), and mycophenolate mofetil (MMF) at 2 and 3 grams daily have demonstrated superior immunosuppressive properties in several recent clinical trials involving solid-organ transplants. An effective immunosuppression may be maintained with lower doses of MMF administered with either tacrolimus or microemulsion cyclosporine.

OBJECTIVE

To compare tacrolimus plus "low-dose" MMF-based immunosuppressive regimen (TMBIR) with Neoral plus "low-dose" MMF-based immunosuppressive regimens (NMBIR) among kidney transplant recipients.

DESIGN

Prospective, randomized study.

PATIENTS

53 consecutive adult recipients of kidney transplant. Both groups (TMBIR and NMBIR) were equally matched on demographic characteristics.

INTERVENTIONS

Participants were randomized to receive orally either tacrolimus (0.08 mg/kg twice daily) (n = 27) or Neoral (4 mg/kg twice daily) (n = 26). Both regimens were started before surgery and continued when allograft demonstrated no postoperative acute tubular necrosis. Both groups received similar "low-dose" MMF (500 mg twice daily) and prednisone (2 mg/kg/day to taper off after 1 year). Switch from tacrolimus to Neoral or vice versa was allowed after refractory rejection or serious adverse events.

MAIN OUTCOME MEASURE

Acute rejection and patient and graft survival 1 year following kidney transplant.

RESULTS

One-year patient survival rates were 88.9% for the TMBIR group and 100% for the NMBIR group; 1-year graft survival rates were 88.9% for the TMBIR group and 96.1% for the NMBIR group. No significant differences were found in the incidence of biopsy-confirmed acute rejection (14.8% TMBIR vs 23% NMBIR). Steroid-resistant rejections requiring cytolytic antibody therapy were higher in the NMBIR group (50% vs 25%). Three patients crossed over from NMBIR to TMBIR for refractory rejections and 1 patient crossed over from TMBIR to NMBIR for new onset seizure. Three episodes of cytomegalovirus infection were observed in the TMBIR group. Other adverse events were similar in both groups.

CONCLUSIONS

Both tacrolimus and microemulsion cyclosporine combined with "low-dose" MMF and corticosteroids provide effective immunosuppression and have similar adverse events in kidney transplant recipients.

Pyrazinoylguanidine in end-stage renal disease: a prospective, placebo-controlled pilot study

Cardiovascular disease is the leading cause of mortality in end-stage renal disease (ESRD) patients receiving dialysis. In these patients, hypertriglyceridemia appears to increase the risk of accelerated atherosclerosis. The present placebo-controlled study evaluated prospectively lipid-lowering effects of pyrazinoylguanidine (PZG) in 6 ESRD patients undergoing maintenance hemodialysis. The design of the study entailed a placebo phase of 1 week followed by 3 weeks of PZG, 400 mg three times a day. Compared to placebo, PZG reduced serum triglycerides (PZG vs. placebo 370 +/- 171 vs. 414 +/- 182 mg/dl; p = 0.01). PZG also tended to decrease total cholesterol. In addition, PZG selectively lowered blood glucose in hyperglycemic patients. PZG was well tolerated; it did not interfere with hemodynamic parameters or alter liver function tests, nutritional parameters or dialysis clearance.

Immunopathogenesis of human immunodeficiency virus

Human immunodeficiency virus (HIV) types 1 and 2 infect cells of the immune system and initiate a robust immune response which counteracts the viral spread but also accelerates the destruction of the immune system. Many pathogenic mechanisms have been proposed which include viral gene products, syncytium formation, direct virus killing of cells, apoptosis, autoimmunity, cytokine and chemokine expression, superantigens, virus directed cell-mediated cytolysis, and disruption of the lymphoid architecture. At present, there is no unifying theory or experimental proof of a single or a predominant mechanism for the pathogenesis of the HIV disease. This review is intended to highlight areas of HIV research relevant to the understanding of HIV immunopathogenesis.

Intravenous immunoglobulin induced-nephropathy: a complication of IVIG therapy

Since the early 1950s, intravenous immunoglobulin (IVIG) preparations are being used in the treatment of hematologic, neurologic, nephrologic, autoimmune, and immunodeficiency disorders. Infusion of IVIG preparations may cause osmotic-induced acute renal failure. Despite the fact that this entity has been reported previously, it is not a widely appreciated complication. A total of 22 reports involving 52 patients in whom renal failure occurred in association with IVIG infusion. The patients' ages ranged from 20 to 82 years. Thirty patients had preexisting renal insufficiency. Rise in serum creatinine was noted after 1-10 days of IVIG infusion and creatinine returned to baseline within 2-60 days of discontinuation. One developed end stage renal disease. There were four fatalities related to complications of renal failure. Histopathology of renal tissue showed osmotically induced tubular injury (5 patients), tubular vacuolization (2 patients), tubulointerstitial infiltrate (1 patient), and cryoglobulin deposits (1 patient). There appears to be no direct relationship between the development of acute renal failure and the type of IVIG. However, underlying renal insufficiency increases the risk of renal failure. In view of the increasing use of IVIG preparations in medicine, it is imperative that clinicians be aware of this unusual form renal injury.

Peloisis hepatis due to Bartonella henselae in transplantation: a hemato-hepato-renal syndrome

BACKGROUND

Bacillary peliosis hepatis is an uncommon but well recognized disease due to disseminated Bartonella infections occurring predominantly in immunocompromised individuals infected with human immunodeficiency virus, type 1. A similar condition in the absence of Bartonella infection when described in organ transplant patients was felt to be secondary to azathioprine and/or cyclosporine.

METHODS

Herein, we report the first case of bacillary peliosis hepatis due to systemic Bartonella henselae infection in a patient after kidney transplant. The patient presented with severe anemia, persistent thrombocytopenia, and hepato-renal syndrome. DNA-based polymerase chain reactions (PCR), which allowed direct detection of both B henselae and quintana DNA in patient's peripheral blood and liver tissue, were used. Indirect immunofluorescence assay for Bartonella serology was performed on peripheral blood.

RESULTS

Histopathology of the liver biopsy demonstrated peliosis hepatis. Indirect immunofluorescence assay for Bartonella serology was positive, and B henselae DNA was identified by PCR in the peripheral blood and liver tissue. Treatment with a 3-month course of oral erythromycin resulted in an excellent clinical response.

CONCLUSIONS

The present case suggests that although various anti-rejection therapies and opportunistic infections are associated with hepatic and renal dysfunction along with bone marrow suppression, the diagnostic evaluation in this situation should include liver biopsy and a careful search for evidence of systemic Bartonella infection, e.g., exposure to cats, Bartonella serology, and Bartonella DNA by PCR. A reduction in immunosuppression and prolonged therapy with antibiotics such as erythromycin will often result in early recovery.

Immunohistochemical study of actin binding protein (p55) in the human kidney

BACKGROUND

In clinical transplantation, "passenger" dendritic cells (DCs) in the allograft have been thought to induce allograft rejection. However, the presence of DCs in the normal human kidney is controversial. Most reports have relied on the examination of MHC class I and II antigen expression in combination with DC morphology for identification of DCs.

METHODS

The distribution of the p55 antigen (fascin), which is selectively expressed by human blood and lymphoid DCs, was investigated by immunohistochemistry.

RESULTS

Our study demonstrates that p55-positive DCs are absent from the normal human kidney and CD1a- and S100-positive cells are absent or very rare. Furthermore, HLA-DR and factor VIII-related antigen show almost complete colocalization in capillaries. In contrast, all 16 kidney biopsies from patients with inflammatory processes demonstrated p55-positive DCs in the cellular infiltrates.

CONCLUSIONS

These results suggest that DCs are not present or are very rare in normal renal tissues but may migrate into the renal interstitium with inflammatory changes.

Intravenous infusion of total dose iron is superior to oral iron in treatment of anemia in peritoneal dialysis patients: a single center comparative study

In the treatment of anemia of chronic renal failure, the most common cause of recombinant human erythropoietin (rhEPO) resistance is iron deficiency. In peritoneal dialysis (PD) patients, oral iron therapy is an accepted and convenient method of iron supplementation. The effectiveness of oral iron, however, is limited by many factors, including gastrointestinal side effects and poor gastric absorption. This study prospectively compared the efficacy of single intravenous infusion of total dose iron (ITDI group) given in an outpatient setting with oral iron (oral group) for the treatment of anemia in PD patients. Twenty-five adult stable PD patients with baseline hematocrit 25 to 35% were entered into the study. Thirteen patients with serum transferrin saturation (TSAT) < 25% received ITDI, and 12 patients with TSAT between 25 and 35% received oral iron. One patient in the oral group received emergent blood transfusion and was excluded from analysis. Hematocrit and iron indices were measured at monthly intervals. Doses of rhEPO were adjusted monthly to maintain target hematocrit at 35%. At the end of the study (6 mo), despite similar baseline mean hematocrit (31.0 +/- 0.9 versus 33.0 +/- 1.0%), comparable mean baseline weekly rhEPO dose (7886 +/- 1449 versus 6370 +/- 1553 U/wk), and significantly lower level of mean TSAT (11.3 +/- 3.5 versus 30.1 +/- 3.5%; P < 0.05), the ITDI group when compared with the oral group had significantly higher mean hematocrit (36.0 +/- 1.0 versus 31.4 +/- 1.1%; P < 0.05) and TSAT (33.7 +/- 3.7 versus 22.6 +/- 4.0%; P < 0.05) values. In addition, the final mean dose of weekly rhEPO was significantly lower in the ITDI group (4799 +/- 981 versus 9998 +/- 1027 U/wk; P < 0.05). No patient in the ITDI group developed an adverse reaction to intravenous iron. It is concluded that ITDI represents a more efficacious method of iron supplementation in PD patients receiving rhEPO. Moreover, ITDI is safe and well tolerated and can be administered in an outpatient setting.

Efficacy of oral ganciclovir in prevention of cytomegalovirus infection in post-kidney transplant patients

Unlike parenteral gancicovir, the efficacy of oral ganciclovir in the prevention and treatment of cytomegalovirus (CMV) infection in kidney transplantation has not been well documented. This study prospectively evaluated the episodes of CMV infection within the first nine months after transplantation in renal transplant recipients treated prophylactically with oral ganciclovir (750 mg twice a day) over a period of 3 months (oral ganciclovir, N = 22), compared with patients randomly assigned as controls (controls, N = 22) who did not receive any anti-viral prophylaxis. Diagnosis of CMV infection at presentation included serological determination of CMV-specific immunoglobulin M antibodies, CMV immunofluorescence assay [standard culture tube and shell vial] (blood) and virus isolation (urine and tissue). CMV infection occurred in one patient (5%) in the oral ganciclovir group and 6 patients (27%) in the control group (p < 0.05). The episodes of biopsy proven allograft rejections were 5% (1/21) and 18% (4/22) in the oral ganciclovir and control groups, respectively. Except for one, none of these patients developed CMV infection either before or after rejection(s). Controlling for the reason (induction or treatment of rejection) for using cytolytic antibody therapies, we found that prophylactic oral ganciclovir was protective against CMV infection (adjusted risk reduction 0.83; 95% confidence interval, 0.33-0.98; p < 0.05). Neither, the CMV status of donors and recipients nor the treatment for acute rejection had any significant impact on the occurrence of CMV infections. Our results show that oral ganciclovir is an effective and well tolerated therapy in the prevention of CMV infection in renal transplant patients.

Pure red cell aplasia due to parvovirus B19 infection in solid organ transplantation

Human parvovirus B19 disease is an infrequent but recognized rare cause of anemia in immunocompromised patients. A few cases of parvovirus B19 infections have been reported in transplant recipients, of those only four patients underwent renal transplantation. The primary immunosuppressive therapy in these patients included prednisone with either cyclosporine or tacrolimus. In one patient the disease was self-limiting, while in three others the hematocrit improved following 10-15 d of treatment with commercial intravenous immunoglobulin (IVIG). Herein, we report the fifth case of pure red cell aplasia due to parvovirus B19 infection in a renal transplant recipient who responded to a 5-d course of IVIG. To our knowledge, this is the first case of parvovirus B19 infection in a patient with solid-organ transplantation whose immunosuppressive regimen included both mycophenolate mofetil and tacrolimus and in whom an excellent clinical response was achieved with a short course of IVIG infusion.

Successful reversal of acute vascular rejection in a renal allograft with combined mycophenolate mofetil and tacrolimus as primary immunotherapy

Despite the use of newer immunosuppressive drugs, early allograft rejection is still a major cause of graft loss and diminished graft survival. The pathological picture of acute interstitial rejection usually responds to high dose steroids, whereas the treatment of acute vascular (AVR) rejection characterized by an intense vasculitis and/or endotheliolitis is more formidable. The use of newer monoclonal antibodies specific for T lymphocytes and their subsets has only been occasionally successful in reversing AVR. Here we report a case of successful reversal of acute vascular renal allograft rejection with mycophenolate mofetil (MMF) and tacrolimus as primary therapy.

Recurrent type I membranoproliferative glomerulonephritis after renal transplantation and protective role of cyclosporine in acute crescentic transformation

Almost all diseases affecting the native kidney may recur in the transplanted kidney, with one of the most frequent being recurrent glomerulonephritis. Among the glomerulonephritides, membranoproliferative glomerulonephritis (MPGN), immunoglobulin A nephropathy (IgA), and focal-segmental glomerulosclerosis (FSGS) have the highest rates of recurrence. Here we report a patient who, after living-related kidney transplantation, suffered allograft loss shortly after surgery due to recurrence of glomerulonephritis. Two weeks prior to transplant nephrectomy light microscopic examination of the allograft biopsy failed to show glomerulonephritis. Subsequent histopathology of the transplant nephrectomy specimen demonstrated a crescentic form of type I MPGN following withdrawal of cyclosporin A (CsA) and intense course or oral steroid therapy. The entity of recurrent type I MPGN in kidney transplantation is reviewed, and a possible protective role of CsA against rapidly progressive crescentic type I MPGN is explored.

Effect of use of vasopressors in organ donors on immediate function of renal allografts

The purpose of this study was to determine whether use of vasopressors in cadaveric donors of renal transplants was associated with an increased prevalence of acute tubular necrosis after kidney transplantation. We compared immediate allograft function in 26 consecutive renal allograft recipients whose donors had been given vasopressors with that in 26 recipients whose donors had nor. The donors treated with vasopressors had been given more than 10 micrograms/kg per minute of dopamine, norepinephrine, or epinephrine, alone or in combination. The groups were matched with respect to donors' age, recipients' disease, and cold ischemic time. The prevalence of immediate allograft function was significantly lower in recipients whose donors had required use of vasopressors (38.5%) than in recipients whose donors had not required vasopressors (65.4%). We conclude that use of vasopressors in kidney donors leads to an increased prevalence of acute tubular necrosis.

Adverse effect of donor vasopressor support on immediate and one-year kidney allograft function

BACKGROUND

This purpose of this study was to determine if there was a significant difference between the rates of acute tubular necrosis (ATN) and long-term graft survival in renal allografts procured from donors requiring inotropic support (DRIS) and those from donors not requiring inotropic support.

METHODS

Eighty-two consecutive cadaveric renal transplant patients were prospectively followed in our local procurement area, the Delaware Valley Transplant Program. Forty-eight patients received organs from DRIS (> 10 mcg/kg per minute of dopamine, dobutamine, epinephrine, and norepinephrine alone or in combination), and 34 did not.

RESULTS

Allografts from the non-DRIS group had an immediate function rate of 82.4% and a 1-year function rate of 91.2%. In comparison, the DRIS grafts had an immediate function rate of 58.3% and a 1-year function rate of 72.9%. These differences were statistically significant. The mean serum creatinine in the non-DRIS group was 1.46 +/- 0.58 mg/dl, whereas in the DRIS cohort it was 1.89 +/- 0.93 mg/dl.

CONCLUSIONS

Kidneys transplanted from DRIS had significantly (1) poorer immediate function, (2) worse 1-year survival rates, and (3) higher serum creatinine at 1 year. We conclude that recipients receiving organs from donors requiring inotropic support are at a higher risk of developing ATN after surgery and experience reduced 1-year function.

Fecal short-chain fatty acids in patients with diarrhea-predominant irritable bowel syndrome: in vitro studies of carbohydrate fermentation

Colonic bacterial production of short-chain fatty acids (SCFA) plays an important role in the salvage of unabsorbed carbohydrate and in colonic absorption of electrolytes and water. The objective of this study was to determine whether patients with diarrhea-predominant irritable bowel syndrome (DP-IBS) have a different pattern and rate of fermentation of carbohydrate and fiber to SCFA compared with controls. Fecal homogenates from 10 patients with DP-IBS and 10 age-matched controls were studied. SCFA were measured by gas chromatography in baseline fecal samples and in fecal homogenates in an in vitro anaerobic fermentation system after incubation with no additional substrate, lactulose, potato starch, citrus pectin, and hemicellulose over a 24-hour period. Net SCFA production rates were calculated for the first 6 h of the incubation period. Patients with DP-IBS had a consistently different pattern of less total SCFA, a lower percentage of acetate (p < 0.05), and a higher proportion of n-butyrate (p < 0.05) than controls. In stool homogenates from both controls and DP-IBS patients, lactulose fermentation resulted in the highest rate of SCFA production followed by pectin, starch, and hemicellulose. However, at all time points, the fecal homogenates from controls generated a higher concentration of total SCFA, acetate, and propionate with all substrates tested. SCFA production rates were higher in controls incubated with lactulose, starch, and hemicellulose. The fecal SCFA profile of patients with DP-IBS is characterized by lower concentrations of total SCFA, acetate, and propionate and a higher concentration and percentage of n-butyrate. Fecal flora from these patients produced less SCFA in an in vitro fermentation system in response to incubations with various carbohydrates and fibers. Differences in SCFA production by colonic bacterial flora in patients with DP-IBS may be related to the development of gastrointestinal symptoms.

Acute renal failure secondary to solid tumor renal metastases: case report and review of the literature

Renal metastases from solid tumors to both kidneys rarely result in acute renal failure (ARF). We present a case of squamous cell pulmonary carcinoma responsible for ARF due to (1) extensive (50% to 75%) bilateral parenchymal infiltration and replacement accompanied by tissue destruction, (2) widespread vascular invasion and thrombosis resulting in ischemia, and (3) histological evidence for foci of distal intratubular obstruction and pyelonephritis. Five additional cases, including one pulmonary cancer, causing ARF from extensive tissue replacement and destruction are reviewed. In a separate case, ARF resulted from lymphatic metastases rather than from parenchymal destruction or obstruction. Common findings in all six reported cases include bilaterally enlarged kidneys and progressive oligoanuria despite correction of prerenal or postrenal conditions. In our patient and in one other prior reported case, extrarenal obstruction was not considered important because invasive therapeutic procedures were unsuccessful in reversing ARF. In one case, irradiation of kidney tumor resulted in reversal of ARF. These cases emphasize the rare potential for solid tumors to metastasize to both kidneys and result in irreversible oligoanuric ARF. A high level of suspicion is required, and an early diagnosis may result in reversible ARF if the tumor is amenable to chemotherapy or irradiation.

The Family Preservation and Support Services Program

Two recent issues of The Future of Children have examined programs that support families with young children: the Winter 1993 issue on home visiting and the Winter 1995 issue on the long-term outcomes of early childhood programs. In both issues, the legislation creating the Family Preservation and Support Services Program was discussed as a possible funding source for such programs. This Revisiting article summarizes the key elements of that federal program and discusses some of the challenges states have faced as they have tried to implement the new law. Thus far, the legislation has had only a modest impact on the availability of services, but it has triggered a comprehensive and broad-based planning process that is likely to have lasting benefits.

Efficacy of bolus intravenous iron dextran treatment in peritoneal dialysis patients receiving recombinant human erythropoietin

The efficient use of recombinant human erythropoietin (rHuEPO) requires adequate body stores of iron. In peritoneal dialysis (PD) patients, iron replacement is most commonly administered orally. In this study, we prospectively followed 7 stable PD patients following bolus intravenous infusion of 1 g iron dextran in an outpatient setting. At 12 weeks, significant (p < 0.05) increments in mean hematocrit from 29.13% to 34.85%, transferrin saturation from 10.15% to 29.33%, serum iron from 27.38 to 67.00 micrograms/dL, and serum ferritin from 150.30 to 331.40 ng/mL were observed. Post-treatment, there was less requirement of rHuEPO, and at six months there was a 26% reduction in the mean weekly subcutaneous rHuEPO dose. At 12 weeks, serum albumin increased significantly from 3.50 to 3.76 g/dL (p < 0.05). There was no abnormality in any of the measured liver function tests. No patient developed an adverse or allergic reaction. We concluded that bolus intravenous infusion of iron dextran is an effective and well-tolerated method of repleting iron stores, and will allow a more efficient and economic use of rHuEPO in PD patients.

Acute renal failure following immunoglobulin therapy

Intravenous IgG infusion has infrequently been reported to cause acute renal failure. In almost all these reports, a sucrose containing IgG product was believed to be the cause of renal injury. Sucrose-induced osmotic nephrosis has been well described in the literature. In this report, we describe a case of acute anuric renal failure following a large infusion of intravenous IgG containing sucrose. Urine cytology demonstrated typical osmotic injury to the renal tubular epithelial cells. Early recovery of renal function was achieved by dialytic removal of sucrose from the circulation.

Gastrointestinal tuberculosis in renal transplantation: a case report and review

The pattern of tuberculosis has changed and in recent years: extrapulmonary tuberculosis has become more common, especially in immuno-compromised individuals. A case of primary intestinal tuberculosis in a patient with kidney transplant is reported. The patient presented with persistent fever and right-sided abdominal pain. Histopathology of colonic tissue showed granulomatous inflammation containing acid fast bacilli, and culture of the tissue grew Mycobacterium tuberculosis. Clinical improvement occurred after institution of appropriate anti-tubercular treatment.

Leprosy-associated renal disease: case report and review of the literature

Leprosy is an infectious disease the principal clinical manifestations of which are anesthetic skin lesions and the development of peripheral neuropathy. The most common renal manifestation in leprosy patients is glomerulonephritis. Both immunofluorescent and electron microscopic studies suggest that the varied glomerular lesions found in these patients are immune complex mediated. Other renal lesions that have been described include amyloidosis, tubulointerstitial disease, acute renal failure, and functional defects in the absence of identifiable histologic abnormalities. In this report, a patient is described who developed the clinical syndrome of rapidly progressive glomerulonephritis. The renal biopsy showed a diffuse endocapillary proliferative process with electron-dense deposits in the glomerular subendothelial and subepithelial spaces. Organisms consistent with Mycobacterium leprae were identified within several of the glomeruli.

Intravenous immunoglobulin-induced osmotic nephrosis

Intravenous immunoglobulin preparations are being used for an increasing number of indications in clinical medicine. To minimize adverse reactions, sugar additives such as sucrose are added to some preparations to serve as stabilizing agents. We describe a patient treated with an immunoglobulin preparation containing sucrose who developed a fully reversible form of acute renal failure with histologic changes characterized by vacuolization and swelling of renal proximal tubular cells. We believe the high concentration of sucrose in the immunoglobulin preparation resulted in osmotic injury to the renal tubules. Such changes, which are identical to those described in humans and experimental animals given intravenous infusions of hypertonic sucrose, have come to be known as osmotic nephrosis. Risk factors for the development of this lesion are renal insufficiency and volume depletion. The risk for such injury can be minimized by further diluting the immunoglobulin preparation and slowing the infusion rate.

Fecal short-chain fatty acids in children with inflammatory bowel disease

Nutrition of colonic epithelial cells (colonocytes) is maintained by luminal short-chain fatty acids (SCFAs), chiefly by n-butyrate. The importance of SCFAs for the maintenance of colonic epithelium has been demonstrated in animal models of colitis produced by rectal instillation of an inhibitor of SCFA oxidation and in patients with diversion colitis in whom a segment of colonic epithelium was deprived of contact with luminal SCFAs. We measured fecal SCFAs and lactate in children with ulcerative colitis (UC; n = 17) and with Crohn's disease with ileocolonic involvement (CD; n = 22) and age-matched controls (n = 12) by a vacuum-distillation, gas chromatographic method. Fecal SCFA concentrations were correlated with scores of clinical disease activity. Patients with UC and CD had a decrease in the fecal concentration of acetate (p < 0.05) and an increase in n-butyrate (p < 0.01) compared with controls. No significant changes in fecal lactate were seen. A comparison of inactive- or mild-UC patients with moderate or severe-UC patients yielded major differences in SCFA concentrations with n-butyrate increased in inactive and mild UC well above control values and total SCFA and acetate decreased in moderate and severe UC below control levels. Raised concentrations of fecal n-butyrate may reflect impaired utilization of this SCFA in the colon of patients with mild UC and Crohn's disease with colonic involvement. Whether this defect is primary or secondary to inhibitors in the colonic lumen, due to impaired transport of n-butyrate into the cell or defective metabolism within the cell, or specific to inflammatory bowel disease remains to be explored.

Evaluation of liquid yeast-derived sucrase enzyme replacement in patients with sucrase-isomaltase deficiency

BACKGROUND

No enzyme replacement therapy exists for patients with congenital sucrase-isomaltase deficiency (CSID). A by-product of the manufacture of baker's yeast is a liquid preparation containing high sucrase activity. The aim of the present study was to investigate the activity and stability of this preparation and its effect on breath hydrogen excretion and gastrointestinal symptoms after sucrose ingestion in 14 patients with CSID.

METHODS

The homogeneity of yeast sucrase was studied by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and its activity was measured. Stability at various temperatures and pH ranges and in the presence of gastric aspirate, pepsin, and bovine serum albumin was assessed. Fourteen patients with CSID underwent double-blind placebo-controlled breath tests with yeast sucrase. They then completed an 8-week dose response study that used different enzyme concentrations while consuming a sucrose-containing diet.

RESULTS

Liquid yeast sucrase is highly glycosylated, contains no lactase activity, and is stable at 4 degrees C and over a wide range of pH. Pepsin digestion of the enzyme in vitro can be blunted by bovine serum albumin and by increasing the pH. Yeast sucrase reduces breath hydrogen excretion in patients with CSID who are given a sucrose load (P < 0.001) and allows most patients to consume a sucrose-containing diet.

CONCLUSIONS

Liquid yeast sucrase offers effective enzyme replacement therapy for patients with CSID.

Retroperitoneal fibrosis

Retroperitoneal fibrosis, an uncommon and ill-defined condition, has a variety of causes and presenting features. The fibrotic process often produces ureteral obstruction and compression of surrounding structures. Pain in the flank, lower abdomen or lumbosacral region is the most common presenting symptom. Certain drugs, neoplasms, retroperitoneal injury or infections may all initiate the fibrotic process. This article describes a case of retroperitoneal fibrosis in a 34-year-old man who had been receiving a beta-adrenergic blocking agent.

Papillary carcinoma of the common bile duct. Diagnosis by bile drainage cytology

A 54-year-old man with clinical and radiologic findings suggestive of pancreatic carcinoma had cytologic examination of bile drainage fluid specimens prepared by membrane filtration and cytocentrifugation. Examination showed clumps of malignant cells with features most consistent with a well-differentiated papillary neoplasm of bile duct origin, rather than a primary pancreatic carcinoma. Partial pancreatoduodenectomy with resection of the proximal common bile duct confirmed the presence of a small, well-differentiated but invasive papillary bile duct carcinoma. Pancreatic carcinoma and papillary carcinoma of the bile duct are anatomically and biologically different lesions that should be distinguished, when possible, by cytologic examination. In this case, surgical treatment was planned on the assumption that cytologic examination could distinguish a papillary carcinoma of the bile duct from the clinically suspected pancreatic adenocarcinoma.

Postoperative wound infection associated with Vibrio parahaemolyticus in a patient without exposure to seawater

This report describes a case of wound infection associated with Vibrio parahaemolyticus. The patient had ingested steamed crabs 7 days before admission for surgical treatment of intestinal obstruction due to colon carcinoma. The Vibrio sp. was isolated from postoperative wound drainage as well as from stool. Recovery was uneventful.

Acute ileotyphlitis as presenting manifestation of acute myelogenous leukemia

A case of acute myelogenous leukemia is reported in a child who presented with acute ileotyphlitis and died of an over-whelming Clostridium septicum sepsis before the chemotherapy was administered. The pathogenesis of acute ileotyphlitis, especially the role of granulocytopenia is discussed.