Ten-year follow-up study of PTSD diagnosis, symptom severity and psychosocial indices in aging holocaust survivors

OBJECTIVE

We performed a longitudinal study of holocaust survivors with and without post-traumatic stress disorder (PTSD) by assessing symptoms and other measures at two intervals, approximately 10 years apart.

METHOD

The original cohort consisted of 63 community-dwelling subjects, of whom 40 were available for follow-up.

RESULTS

There was a general diminution in PTSD symptom severity over time. However, in 10% of the subjects (n=4), new instances of delayed onset PTSD developed between time 1 and time 2. Self-report ratings at both assessments revealed a worsening of trauma-related symptoms over time in persons without PTSD at time 1, but an improvement in those with PTSD at time 1.

CONCLUSION

The findings suggest that a nuanced characterization of PTSD trajectory over time is more reflective of PTSD symptomatology than simple diagnostic status at one time. The possibility of delayed onset trajectory complicates any simplistic overall trajectory summarizing the longitudinal course of PTSD.

Care of the renal transplant recipient: a field guide for the generalist

More than 60,000 kidney transplant recipients currently live in the United States. It is not uncommon for these persons to receive medical care through a primary care physician. The widely held belief that only physicians and surgeons with "special knowledge" can care for these patients is clearly not the case. In addition to considering the immediate posttransplantation problems, this section attempts to demystify the care of kidney transplant recipients beyond the first few months of recovery after surgery. It also serves as a guide to help determine which problems can be handled by a primary care physician and which indicate referral back to the transplant center. Common infectious problems, both bacterial and viral, are discussed. This section also considers metabolic abnormalities such as hypertension, increased lipids, gout, calcium/bone diseases, and hematologic issues. Common conditions that cause real or perceived decreases in function but are not related to graft rejection are also explained.

Race and delayed kidney allograft function

BACKGROUND

Allograft survival among black recipients is poorer than among whites. Delayed allograft function is associated with a significant reduction in renal allograft survival. The relationship between delayed allograft function and black race is incompletely specified and was the focus of this investigation.

METHODS

A non-concurrent study of 325 recipients of cadaveric allografts followed for the occurrence of delayed allograft function defined as dialysis during the first week following transplantation for the principal analysis. A secondary definition of delayed allograft function was formulated based on the serum creatinine 2 weeks after transplantation. Unadjusted and adjusted logistic regression analysis were used to examine the unconfounded relationship between race and delayed allograft function.

RESULTS

Fifty-seven of 91 (62.6%) black recipients experienced delayed allograft function compared to 113 of 234 (48.3%) whites. The odds ratio for black race as a predictor of delayed allograft function was 1.80, P=0.02, (95% CI, 1.09, 2.95). This finding was stable despite adjustment for other predictors of delayed allograft function in a multivariate model, but the precision of this estimate was less (P=0.10) because of missing data. Additionally, adjusted models with imputed values for missing covariates, models using a secondary definition of delayed allograft function, and models excluding patients whose cyclosporin therapy was delayed, all consistently demonstrated a similar association between black race and delayed allograft function.

CONCLUSIONS

This study demonstrated an increased risk of delayed allograft function among black recipients. This relationship may play a role in the poorer allograft outcomes experienced by black recipients. Given the negative effect of delayed allograft function on allograft survival, efforts to identify its modifiable risk factors should be a high priority.

Focal acute tubular necrosis in a renal allograft

Nuclear imaging is used to evaluate renal allografts demonstrating delayed function after transplantation. Interpretation of the nuclear scan in the context of clinical data, provides helpful information in the management of the transplant recipient. The better quality of images obtained with technetium-99m mercaptoacetyltriglycine (Tc-99m MAG3) has made it the radiotracer of choice compared to technetium-99m diethylenetriamine pentaacetic acid (Tc-99m DTPA) for imaging of the renal allograft. Tc-99m MAG3 is cleared from the kidney by tubular secretion, whereas Tc-99m DTPA is cleared by glomerular filtration. In this report, we discuss a unique abnormality found on nuclear imaging of a renal allograft. Utilizing our understanding of the characteristic handling of various radiotracers by the kidney, we were able to demonstrate that the renal scan was consistent with an area of focal acute tubular necrosis in the newly transplanted kidney.

Effect of anti-lymphocyte induction therapy on renal allograft survival: a meta-analysis

Induction immunosuppression with antilymphocyte antibodies has not been shown to improve cadaveric kidney allograft survival in randomized, controlled trials despite widespread use. This meta-analysis of randomized, controlled trials assessed the effectiveness of induction therapy in prolonging allograft survival. Studies of induction therapy were identified in Medline (1986 through 1996), using the terms "monoclonal antibodies" or "antilymphocyte serum," and "kidney transplantation," "human," and "clinical trial." Bibliographies, pharmaceutical manufacturers, the United Network for Organ Sharing, National Institutes of Health, and study authors were also consulted. Seven of 247 identified studies met the following inclusion criteria: (1) an adult study population; (2) assessment of antilymphocyte antibodies in the immediate posttransplant period; (3) a control arm of cyclosporine, azathioprine, and prednisone in the immediate posttransplant period; and (4) presentation of survival data. Two readers independently extracted protocol and survival data from each study. Summary odds ratios (fixed and random effects) and a rate ratio from proportional hazards regression at 2 yr were estimated to examine the effect of induction therapy on allograft survival. The summary odds ratios were both 0.66 (confidence interval [CI], 0.45 to 0.96; P = 0.03), and the rate ratio was 0.69 (CI, 0.49 to 0.97; P = 0.03), indicating a beneficial effect of induction therapy on allograft survival. Allograft survival was 85.6% (CI, 82.1 to 89.1%) in the induction therapy group and 79.6% (CI, 75.6 to 83.6%) in the conventional therapy group. These results were stable in a sensitivity analysis based on study quality. Allograft survival was prolonged with induction therapy compared with conventional immunosuppression. These data indicate a potential role for the routine use of induction therapy in renal transplantation to optimize the survival of cadaveric allografts.

National kidney allograft sharing: a decision analysis

BACKGROUND

Expansion of the current program of national sharing of cadaveric kidney allografts is of uncertain benefit, and the logistical barriers to expanding organ sharing are large. This study estimated the improvement in allograft survival from expanding organ sharing in the United States.

METHODS

A decision analysis based on allograft survival data from cadaveric allograft recipients throughout the United States compared the mean allograft survival resulting from four allograft-sharing strategies: no national sharing, national sharing of allografts matched at 6 histocompatibility alleles, national sharing of allografts matched at 4 or more alleles, and national sharing of allografts matched at 2 or more alleles.

RESULTS

Sharing allografts matched at 4 or more alleles was optimal (mean allograft survival=6.35 years). This survival was little better than the mean survival of the other three strategies (no national sharing, 6.21 years; national sharing of allografts matched at 6 alleles, 6.31 years; and sharing of allografts matched at 2 or more alleles, 6.33 years). The increment in the proportion of allografts surviving 4 years or more under the optimal strategy compared with no national sharing was <2%. A similar decision model comparing kidney transplant outcomes before and after the introduction of cyclosporine showed that this drug has had a much greater impact on mean allograft survival than would be expected to occur with national allograft sharing: 6.07 years with cyclosporine versus 3.79 years without cyclosporine.

CONCLUSIONS

Expanding national allograft sharing would achieve little improvement in mean allograft survival. The limited benefit and logistical barriers to expansion of allograft sharing should be considered before following recommendations to expand the current U.S. allograft-sharing program.

Delayed function reduces renal allograft survival independent of acute rejection

BACKGROUND

Mechanisms by which delayed allograft function reduces renal allograft survival are poorly understood. This study evaluated the relationship of delayed allograft function to acute rejection and long-term survival of cadaveric allografts.

METHODS

338 recipients of cadaveric allografts were followed until death, resumption of dialysis, retransplantation, loss to follow-up, or the study's end, which ever came first. Delayed allograft function was defined by dialysis during the first week following transplantation. Multivariate Cox proportional hazards survival analysis was used to assess the relationship of delayed allograft function to rejection and allograft survival.

RESULTS

Delayed allograft function, recipient age, preformed reactive antibody levels, prior kidney transplantation, recipient race, rejection during the first 30 days and rejection subsequent to 30 days following transplantation were predictive of allograft survival in multivariate survival models. Delayed allograft function was associated with shorter allograft survival after adjustment for acute rejection and other covariates (relative rate of failure [RR]+1.72 [95% CI, 1.07, 2.76]). The adjusted RR of allograft failure associated with any rejection during the first 30 days was 1.99 (1.23, 3.21), and for rejection subsequent to the first 30 days was 3.53 (2.9 08, 6.00). The impact of delayed allograft function did not change substantially (RR=1.84 [1.15, 2.95]) in models not controlling for acute rejection. These results were stable among several subgroups of patients and using alternative definitions of allograft survival and delayed allograft function.

CONCLUSIONS

This study demonstrates that delayed allograft function and acute allograft rejection have important independent and deleterious effects on cadaveric allograft survival. These results suggest that the effect of delayed allograft function is mediated, in part, through mechanisms not involving acute clinical rejection.

Recipient body size and cadaveric renal allograft survival

Transplantation of renal allografts inadequate to meet recipient metabolic demands has been hypothesized to be one cause of chronic allograft failure. This cohort study examined the relationship of each of three measures of recipient body size and one measure of recipient metabolic rate to the rate of allograft failure among 239 recipients of cadaveric renal allografts between 1985 and 1990. All subjects were followed until allograft failure, death, or December 31, 1992, whichever occurred first. Using multivariate Cox proportional hazards analysis, all measures of recipient size and metabolic rate were found to be strong and statistically significant predictors of allograft survival adjusted for other predictors of allograft survival including allograft rejection, delayed allograft function, recipient race, prior renal transplantation, and donor age. The adjusted relative risk (RR) of allograft failure for a 15-kg increase in recipient body weight was 1.47, P < 0.0001 (95% confidence interval (CI), 1.21-1.78); adjusted RR for a 10-U increase in recipient body mass index was 2.34, P < 0.0001 (95% CI, 1.53-3.58); adjusted RR for a 0.5 m2 increase in recipient body surface area was 2.34, P < 0.001 (95% CI, 1.40-3.91); and adjusted RR for a 250 Kcal increase in metabolic rate was 1.49, P < 0.01 (95% CI, 1.17-1.89). These results are consistent with prior research indicating that a renal tissue supply-demand mismatch may accelerate failure of renal allografts. Alternative explanations of this relationship between recipient body size and allograft survival include inadequate immunosuppressive medication administration among recipients with a larger body size. Additional research is warranted to examine more fully the relationship between recipient body size and allograft survival.

Reversal of acute renal allograft rejection by extracorporeal photopheresis: a case presentation and review of the literature

There is a clear need for well-tolerated immunomodulatory agents that can aid in the prevention of acute solid organ rejection. Extracorporeal photopherosis is an apheresis-based therapy that is currently available at many medical centers worldwide. Preliminary studies utilizing photopheresis with standard immunosuppressives have shown this therapy to successfully reverse acute cellular rejection of cardiac allografts with minimal toxicity. No formal evaluation of the role of extracorporeal photopheresis had been performed in renal transplantation. In this report, photopheresis was successfully utilized to treat acute cellular rejection in a patient with a renal allograft. This lends further support to the existing literature suggesting that photopheresis may be useful for the reversal of acute solid organ rejection. Although our experience with this patient is anecdotal, photopheresis merits further study as treatment for severe renal allograft rejection.

Women cannot discriminate between different paracervical block techniques applied to opposite sides of the cervix

The purpose of this study was to determine whether women can discriminate better from less effective paracervical block techniques applied to opposite sides of the cervix. If this discrimination could be made, it would be possible to compare different techniques and thus improve the quality of paracervical anesthesia. Two milliliters of local anesthetic was applied to one side and 6 ml to the other side of volunteers' cervices before cervical dilation. Statistical examination was by sequential analysis. The study was stopped after 47 subjects had entered, when sequential analysis found that there was no significant difference in women's perception of pain. Nine women reported more pain on the side with more anesthesia and eight reported more pain on the side with less anesthesia. Because the amount of anesthesia did not make a difference, the null hypothesis (that women cannot discriminate between different anesthetic techniques) was accepted. Women are not able to discriminate different doses of local anesthetic when applied to opposite sides of the cervix.

Beneficial effect of low-dose systemic retinoid in combination with topical tretinoin for the treatment and prophylaxis of premalignant and malignant skin lesions in renal transplant recipients

Renal transplant recipients experience a greatly increased frequency of neoplastic skin lesions, including aggressive squamous cell carcinomas. Recent reports suggest that high doses of systemic retinoids may exert a chemotherapeutic and chemoprophylactic effect. Similarly, topical retinoid, especially tretinoin, has also been shown to be anti-tumoragenic in various settings. Because of the serious toxicity of high-dose systemic retinoid, a protocol was developed that combined topical tretinoin with low-dose etretinate (10 mg daily) for the treatment of frequently occurring dysplastic skin lesions in renal transplant recipients. Seven patients elected to receive combined tretinoin and etretinate therapy, and 4 were treated with tretinoin alone. Clinical evaluations were performed monthly. By 3 months of therapy, 9 of 11 patients exhibited at least a 25% decrease in the number of neoplastic growths. After 6 months, 6 of 8 evaluable patients, including 2 of 3 individuals receiving tretinoin alone, exhibited at least a 50% decrease. Three of 4 patients on the combined regimen and 2 of 3 receiving tretinoin alone for at least 9 months, exhibited a significant decrease in the rate of development of new squamous cell cancers. At the start of treatment, epidermal specimens were almost completely devoid of Langerhans cells (CD1+ cells). Their density increased greatly and in proportion to the duration of therapy. Long term topical tretinoin with or without low-dose oral etretinate seems to be an effective regimen to suppress the development of new tumors and to reduce the numbers of existing lesions in renal transplant recipients.

Nurse-physician collaboration and decision outcomes in transplant ambulatory care settings

OBJECTIVE

This study examined the nature of nurse-physician collaborative practice as reflected in problems presented by transplant patients in telephone contacts with clinical nurse specialists (CNSs).

DESIGN

Exploratory descriptive study.

SAMPLE/SETTING

The sample consisted of 202 renal and renal-pancreas transplant recipients who telephoned nurses at the outpatient clinic of a tertiary care medical center.

METHODS

Over a period of 6 weeks, using a data collection form, nurse specialists recorded the types and frequencies of problems described by transplant patients via telephone interaction and categorized the outcomes of decisions.

RESULTS

Of the 437 calls, averaging 2.16 calls per patient, problems were classified as general questions (46%), medication related (32%), and clinical signs and symptoms (22%) such as fever, rejection, colds, and urinary tract infections. Decision outcomes (n = 354) categorized as independent or collaborative for problem resolution were: CNS only (80%), MD only (11%), and collaborative (9%).

CONCLUSIONS

Resolution of 80% of patients' problems presented in telephone interactions shows that advanced practice nurses play a pivotal role in the delivery of care to outpatient transplant recipients. Independent decision making on the part of the nurse occurs within the context of ongoing collaboration and communication with physician colleagues.

How frequently is emergency contraception prescribed?

A 1993 survey of 294 reproductive health care providers, family practitioners and emergency room physicians investigated the frequency of prescribing emergency contraception. Hormonal emergency contraception had been prescribed by respondents an average of 3.4 times in the preceding 12 months. Almost one-third of the prescriptions were for rape victims, the majority written by emergency physicians. Fifteen IUD insertions for emergency contraception were performed in the preceding year. Few respondents had ever discussed emergency contraception with patients or had literature available on the topic.

Care of the organ transplant recipient

BACKGROUND

Organ and tissue allografting is now a commonly performed procedure. Patients receiving allografts and immunosuppressive medication are no longer restricted to a few specialized centers and areas of the country. Because transplant recipients are leading longer and healthier lives, these patients are appearing in diverse medical settings where expertise in transplantation is not generally established. Because many generalist and specialist physicians can expect to treat this group of patients, it is important that information about the care of transplant patients and their particular problems and needs be made more accessible to other physicians.

METHODS

The authors have compiled the most numerous questions and problems from referring physicians, emergency department physicians, and housestaff and have reviewed the recent literature pertinent to particular issues.

RESULTS AND CONCLUSIONS

This review addresses some of the common problems and myths that surround transplant recipients and discusses how best to initiate care for these patients, particularly when they seek treatment from a nontransplant physician. This review is not exhaustive, but rather a field guide to the initial care of this group of patients. The notion that only those with specialized knowledge can care for these individuals must now be relinquished so that these patients can enter the mainstream of medical care.

Balloon dilation of ureteral strictures after renal transplantation

Ten ureteral strictures that developed in nine patients after renal transplantation were managed with balloon catheter dilation and placement of a ureteral stent. Four strictures were successfully dilated (40%), with a follow-up of 15-42 months (mean, 29 months). Comparison of these cases with the six cases of unsuccessfully dilated strictures failed to show any substantial differences between the groups with respect to demographics, stricture characteristics, or radiologic management techniques. However, strictures that developed at the ureteroneocystostomy site responded favorably more often (three of four strictures) to balloon catheter dilation than did strictures in other locations. The authors' experience is not as favorable as that of others who have managed renal transplant-related ureteral strictures in a similar manner. Nonetheless, their experience reinforces the efficacy of balloon catheter dilation of ureteral strictures that develop after renal transplantation as an effective alternative to surgical revision in a substantial percentage of patients.

A recent decrease in the time to development of monomorphous and polymorphous posttransplant lymphoproliferative disorder

We have noted a decrease in the time to development of posttransplant lymphoproliferative disorder (PTLD) over the last two and one-half years in our multiorgan transplant program. From February 1965 until December 1990, 1622 transplants were performed including 1489 kidneys (KTxp), 87 livers (LTxp), and 46 pancreata. Between February 1965 and July 1988 (group 1), there were 1260 transplants performed and nine cases of either monomorphous PTLD (M-PTLD, n = 8) or polymorphous PTLD (P-PTLD, n = 1) were diagnosed. The mean time to development of PTLD was 163 +/- 128 weeks, all after KTxp. Five of these nine patients received haploidentical living-related grafts. All patients had presented with advanced disease, none had transplant nephrectomy, and all died of their disease. Between July 1988 and December 1990 (group 2), 362 transplants were performed, and four cases of M-PTLD and three cases of P-PTLD were recognized. Of the seven cases of PTLD in group 2, six developed within 90 days posttransplant (early PTLD). The mean time to development of PTLD was 11 +/- 16 weeks. This was significantly earlier than group 1 (P less than .01). Four of the five cases after KTxp had a 1 or 2 DR-matched donor. Five of these seven patients had serological evidence of recent Epstein-Barr Virus infection, and four of these five had received OKT3 and then developed early PTLD. In group 2, three patients are alive 7-15 months after KTxp nephrectomy, the remaining four have died. We hypothesize that risk factors for the development of PTLD may include heavy immunosuppression, including the use of OKT3, good DR matching, and active EBV infection. Treatment should include graft removal, if applicable, and reduction or cessation of immuno-suppression.

Normocalcemia thirteen years after successful parathyroid allografting in a recipient of a renal transplant

Two months after receiving a cadaveric renal allograft, a 36-year-old woman received a parathyroid allograft from a living unrelated donor, who was haploidentical to the renal donor. Her preoperative 24-hour urinary excretion of calcium was 0.18 gm/24 hrs, and after operation it decreased to 0.004 gm/24 hrs, (normal, less than 0.20 gm/24 hrs). The C-terminal parathyroid hormone level increased from 155 pg/ml (normal, 275 to 675 pg/ml) to 327 pg/ml after operation. The N-terminal parathyroid hormone level in her grafted arm has varied between 2.5 to 10 times the level in her nongrafted arm. Thirteen years later, both allografts are functioning normally. To our knowledge, this is the longest functioning parathyroid allograft.

Changes in causes of death after renal transplantation, 1966 to 1987

This descriptive study was undertaken to examine survival and changes in cause of death after renal transplantation. One fourth (259) of the 1,022 patients who received a renal transplant between 1966 and 1987 at the University of Pennsylvania had died by January 1, 1988. Causes of death for 246 (96%) of the deceased patients were analyzed. Despite an increase in age and number of comorbid diseases before transplantation, posttransplant survival increased significantly over the study period. All-cause mortality rates at 1, 2, and 5 years decreased significantly. Infectious disease cumulative mortality rates at 1, 2, and 5 years also decreased between 1966 and 1985. No trend in the 1-, 2-, or 5-year cardiovascular disease cumulative mortality rates was detected. The decline in the rate of deaths due to infection led to a decrease in the proportion of infection-related deaths and an associated increase in the proportion of cardiovascular disease-related deaths. The reduction in mortality over the past 2 decades is associated with the simultaneous improvement in immunosuppression and treatment of infectious diseases.

Renal transplantation despite a positive antiglobulin crossmatch with and without prophylactic OKT3

The antiglobulin crossmatch (AGXM) is a sensitive technique employed by many transplant centers to enhance detection of preformed antibody to donor antigens that may cause hyperacute rejection. However, positive AGXM may detect irrelevant or very low titers of anti-HLA antibody precluding transplantation in suitable recipients. To investigate the significance of a positive AGXM, cadaveric renal transplantation was carried out despite a weakly positive AGXM (defined as cell killing above background but not greater than 20%) in 48 recipients. In an initial group (n = 10), maintained on triple therapy (cyclosporine, azathioprine, and prednisone), accelerated acute rejection occurred in 4 recipients and 3 grafts were lost. A subsequent group (n = 38) was treated with a prophylactic course of OKT3 then triple therapy. There were no episodes of accelerated acute rejection (P less than 0.01) although clinical hyperacute rejection claimed one graft and the incidence of delayed graft function was high (75%). The prophylactic OKT3 group had a reduced incidence of acute rejection (0.5 versus 1.0) per recipient and the onset of first episodes was delayed (mean onset: 13 versus 35 days after transplantation). One year actuarial primary graft survival was 88% in the prophylactic OKT3 group as compared with only 50% in the initial group. The outcome in the positive AGXM group was similar to a concurrent group (n = 32) with a negative AGXM and immediate graft function. On the other hand, the subset of positive AGXM regraft recipients treated with prophylactic OKT3 fared poorly, with a 36% (4/11) incidence of primary nonfunction. In summary, a positive AGXM, as defined in this report, is not a contraindication to primary renal transplantation--in fact, the use of the AGXM will identify recipients that would benefit from prophylactic OKT3.

Adrenal suppression and steroid supplementation in renal transplant recipients

The use of increased dosages of glucocorticoids during periods of physiologic stress in allograft recipients represents a clinical dilemma in that the short-term exogenous therapy required may significantly impair wound healing and immunocompetence. To investigate whether "stress steroids" are actually necessary, a prospective study was conducted in 40 renal allograft recipients admitted with significant physiologic stress. Stress categories included sepsis, metabolic abnormalities, and surgery. These patients received only their baseline prednisone immunosuppression (5-10 mg/day) and no supraphysiologic or stress doses of glucocorticoids. The clinical course of the patients revealed no evidence of adrenal insufficiency. There was no mortality, increase in hospital stay, or eosinophilia. Five episodes of hyponatremia and seven instances of hypotension were attributed to primary disease processes and responded promptly to specific treatment without steroid supplementation. Biochemical evaluation during stress revealed suppression of ACTH levels in 74.5% of episodes, elevation of urinary free cortisol levels in 79.1% of episodes, and elevation of isolated serum cortisol levels in 55.9% of episodes. This suggested that these patients had physiologically adequate adrenal function. The cosyntropin stimulation test overestimated the incidence and degree of clinically significant adrenal dysfunction (63% of patients) and was not a useful indication of a requirement for additional glucocorticoids. We conclude that functional adrenal suppression is uncommon in renal allograft recipients receiving baseline prednisone immunosuppression (5-10 mg/day) and that the demands of physiologic stress are met by a combination of endogenous adrenal function plus exogenous, baseline, immunosuppressive doses of glucocorticoids. Supra-physiologic or high doses of so-called "stress steroids" are not required. The cosyntropin stimulation test has significant clinical limitations and did not serve to alter clinical care.

Prophylaxis of serious cytomegalovirus infection in renal transplant candidates using live human cytomegalovirus vaccine. Interim results of a randomized controlled trial

We report the interim results of a randomized, double-blind, placebo-controlled, clinical trial of prophylactic, live, attenuated cytomegalovirus (CMV) vaccination (Towne strain of CMV) of renal transplant candidates (RTCs). One hundred seventy-two RTCs were treated and subsequently underwent transplantation and followed up for at least one year and up to five years after transplantation. Eighty-eight RTCs received vaccine, and 84 received placebo. Results were analyzed according to the prevaccination serologic status (anti-CMV antibody titer) of the recipient (R- or R+) and the donor (D- or D+). The overall incidence of CMV disease was highest in the R-D+ group and almost absent in the R-D- group. There was no difference in the incidence of CMV infection or disease between vaccinated and respective placebo control recipients in either the R-D+, R+D+, R+D-, or R-D- groups. In contrast, the severity of CMV disease was significantly decreased in R-D+ vaccinees vs R-D+ placebo-treated recipients. Moreover, in the R-D+ group, one- and five-year cadaver renal allograft actuarial survival rates were 73% and 62%, respectively, for CMV vaccinees vs 40% and 25%, respectively, for control placebo patients. We conclude that seronegative cadaver RTCs may benefit from vaccination with live, attenuated, Towne strain CMV vaccine before transplantation.

A survey of prescribing habits for high-estrogen oral contraceptives

A simple survey was made of health-care providers to determine their attitudes toward oral contraceptives containing more than 50 mcg of estrogen. It was found that about two-thirds of respondents prescribe this group of medication, although few do so regularly. Their use seemed correlated with providers 40 years of age or older. Even members of an association of professionals interested in contraception frequently used these pills. Although this group of contraceptives is being phased out, it is felt that professionals should have ceased their use long ago.

Effects of basolateral ouabain, amphotericin B, cyanide and potassium on amiloride noise during voltage clamp of Rana pipiens skin support sodium-amiloride competition

In a previous study, the amiloride-induced corner frequency (fc) was found to decrease as apical sodium was increased. This effect was small or absent when the basolateral surface was exposed to high potassium. It has been suggested that the apical sodium effect may be indirect, due either to increased intracellular [Na+] which repelled amiloride or to an increased potential at the apical surface which reduced amiloride affinity. High basolateral K+ might then suppress the sodium effect either by preventing intracellular [Na+] from increasing or by allowing a better clamp of the apical membrane potential by reducing basolateral membrane resistance and potential. We checked the effects of basolateral [K+], of cyanide and of ouabain at concentrations known to increase intracellular [Na+]. We found only negligible effects on fc. In addition, amphotericin B added to the basolateral bathing solution either in 115 mM Na+ or in 120 mM K+ had no significant effect on fc. We found that relatively wide variation in clamp potential under all conditions, even with active transport severely inhibited, left fc virtually constant. Since the amiloride kinetics were independent of clamp potential, we were able to measure paracellular and transcellular conductances separately by examining the voltage dependence of clamp current (linear) and amiloride noise power (quadratic). This made possible estimation of channel density and single-channel current.

Recurrent sickle cell nephropathy in a transplanted kidney

Of patients who developed end-stage renal disease secondary to sickle cell anemia (SCA), some have undergone renal transplantation with reasonable success. We recently cared for a patient with SCA and a functioning, transplanted kidney who experienced a permanent decline in renal function three and one-half years following transplant. The evaluation of his renal dysfunction revealed multiple features to support recurrence of sickle cell nephropathy as the cause for the deterioration.

Autoerythrocyte sensitization worsened by a copper-containing IUD

Autoerythrocyte sensitization (Gardner-Diamond syndrome) causes painful ecchymoses, and usually occurs in young women. It is rare and of unknown etiology. The young woman in this report probably had the condition beginning at age 14, but the diagnosis was not made until age 19, shortly after a copper-containing intrauterine device (IUD) exacerbated her condition. The ecchymoses disappeared when the IUD was removed, but recurred when replaced. A non-copper IUD caused no ecchymoses. Taping a copper penny to the skin caused a similar rash. It seems that in this woman, the Gardner-Diamond syndrome was markedly worsened by exposure to copper.

Percutaneous transluminal angioplasty. The procedure of choice in the hypertensive renal allograft recipient with renal artery stenosis

A retrospective review of 547 renal transplants performed over a six-year period revealed allograft renovascular hypertension secondary to RTAS in 39 (7.1%) patients. Percutaneous transluminal angioplasty (PTA) resulted in immediate cure or improvement in 76% of the patients, increasing to 83% in patients with functioning kidneys at a mean follow-up period of 30 months (1-72 months). The renal artery stenosis (RTAS) was equally distributed between living-related and cadaver kidney recipients and did not appear to be more prevalent in end-to-end or end-to-side anastomoses. The blood pressures fell from pre-PTA levels of 167 +/- 22 mmHg systolic to 141 +/- 23.7 post-PTA and 102 +/- 11 mmHg diastolic pre-PTA to 88 +/- 12 mmHg post-PTA (P less than 0.01). Of 25 cured or improved patients, 24 are on significantly less hypertensive medication. Two patients died of causes unrelated to the PTA and only one patient lost a kidney because of the procedure. Compared with operation, PTA is a safer and more effective procedure for the initial treatment of RTAS.

Adverse effect of splenectomy on the survival of patients with more than one kidney transplant

Risk factors associated with death were identified in a cohort of patients who received 2 or more kidney transplants. Data on 19 variables were collected by chart review on 774 patients who received allografts between 1973 and 1980 at any one of 3 hospitals in Philadelphia. 124 of the patients received two or more transplants and were followed for a minimum of 1.5 years. Modified life table analyses of single variables indicated that 7 factors--splenectomy, donor source, age, transplant hospital, number of HLA mismatches, donor sex, and survival time of the prior graft--were significantly related to patient survival. Using all 19 variables, the proportional hazards model was fit to the data. The characteristics most related to survival were splenectomy (P less than .001), donor source (P = .0022), and age (P = .0015). The other 4 factors that were significant on univariate analysis were not significant in this multivariate analysis. The relative risk of death was 5.5 for patients who had had a splenectomy compared with those who had not had a splenectomy. Patients who had received more than one transplant were compared with patients who had received only one transplant, and a subset of recipients of primary transplants who returned to dialysis after primary graft failure. Survival of patients who had received one transplant was approximately the same as that of the retransplanted population. When the proportional hazards model was fit to the populations that received one transplant and compared with the model for the retransplanted group, only age and donor source were common to all three models. The effect of splenectomy on survival was significant for the total population of primary transplant recipients but had no effect on the survival of the subset of recipients whose kidney grafts had failed and were returned to hemodialysis. Infection accounted for 45% of the deaths among splenectomized, retransplanted patients. A higher percentage of septic deaths occurred in patients whose grafts were functioning at the time of death when compared with patients who had returned to dialysis after secondary graft failure. Although retransplantation alone is not associated with an increased mortality, retransplantation in splenectomized patients carries a high risk of death.

Treatment of lymphocele in renal allograft recipients

Retroperitoneal lymphoceles developed in 12 renal allograft recipients during the last nine years. The interval between transplantation and the development of symptoms averaged seven months. The specific syndrome suggesting the presence of a lymphocele included lower abdominal swelling, weight gain, and, occasionally, fever without an obvious source of infection. Although these symptoms mimicked allograft rejection, diagnosis was easily made by ultrasound and intravenous pyelogram. Surgical marsupialization of the lymphocele with drainage into the peritoneal cavity proved to be an effective treatment.

Contrast medium pooling in cystic renal carcinoma: CT findings

This case report describes a serendipitously diagnosed renal carcinoma in a transplant donor. Computed tomography was instrumental in establishing the true nature of this mass based on its ability to demonstrate pooling of contrast material and staining of discrete septae on dynamic postcontrast scans.

Effects of diuretics on plasma volume in pregnancies with long-term hypertension

The purpose of this randomized, prospective study was to investigate the effects of diuretics on plasma volume findings and perinatal outcome in pregnancies complicated by mild long-term hypertension. Twenty patients were in their first trimester and were receiving diuretics at time of entry to the study: Ten patients were allowed to continue their diuretic medication throughout pregnancy (diuretic group), whereas for the other 10 patients, diuretics were discontinued immediately. Plasma volume was serially measured throughout pregnancy with the use of the Evans blue dye-dilution technique. Initial plasma volume was similar in the two groups. However, in the diuretic group, subsequent plasma volume findings at various stages of gestation were markedly reduced when compared to respective plasma volume findings in the other group. In addition, plasma volume expansion was minimal in the diuretic group (mean increase of 18%), whereas it was normal in the other group (mean increase of 52%). Two patients in the diuretic group and one patient in the other group required other antihypertensive medication. There was no difference in perinatal outcome between the two groups. These results suggest that in hypertensive pregnancies, diuretics prevent normal plasma volume expansion without influencing perinatal outcome.

Towne-vaccine-induced prevention of cytomegalovirus disease after renal transplants

91 renal transplant candidates were randomised to receive Towne strain cytomegalovirus (CMV) vaccine or placebo at least 8 weeks before transplantation. The vaccine was well tolerated and there was no vaccine virus excretion. Serological and cellular immune responses developed in most vaccines but were lower in the transplant patients than in healthy volunteers and some of the seronegative patients failed to mount responses. CMV infection occurred in most of the seronegative vaccine-treated or placebo-treated patients who received kidneys from seropositive donors, but the illnesses were less severe in the vaccines than those in similarly exposed placebo-treated patients. Vaccine-treated patients who received kidneys from seronegative donors did not excrete virus, and therefore the vaccine virus was not reactivated from a putative latent state despite immunosuppression at the time of transplantation.

Mycobacterial infections in renal allograft recipients

Primary mycobacterial infections developed in five of 565 patients who had transplants during a 15-year period. All had negative PPDs and normal chest roentgenograms; none had tuberculosis before transplantation. Atypical mycobacteria were cultured in three of five infections. All were treated with a multiple-drug regimen, including isoniazid, rifampin, ethambutol, and streptomycin sulfate. In four of five patients, there were serious drug-related complications. No major initial alteration of immunosuppressive therapy was necessary in any of the patients. During the study, a treatment policy was followed that included one year of isoniazid treatment of all recipients with a positive PPD, history of tuberculosis, chest x-ray film suggestive of tuberculosis, or PPD-positive donor. An additional 14 transplant recipients were treated in accordance with this policy without complications or subsequent mycobacterial infections (32-month average follow-up). Despite the low incidence of mycobacterial infection in this series, the potential lethality and morbidity mandate constant vigilance.

Percutaneous transluminal angioplasty treatment of renal transplant artery stenosis

Since June 1979, percutaneous transluminal angioplasty (PTA) has been the procedure of choice for renal transplant artery stenosis (RTAS) at the Hospital of the University of Pennsylvania. Of 241 renal allograft recipients, 17 (7%) when studied by arteriogram because of suspected RTAS proved to have significant stenosis (the mean reduction in luminal width for the group being 68%) and underwent PTA. RTAS was equally prevalent in cadaver and related kidney allografts and was no less common in HLA-identical related donor grafts, arguing against the importance of immune factors in etiology. RTAS was equally prevalent whether the anastomotic technique was end to end or end to side. However, when RTAS occurred after end to side anastomoses, it was usually postanastomotic. Fifteen of 17 of the attempts at dilation by PTA were successful by angiographic analysis. Thirteen of the 15 successfully dilated patients had long-term allograft survival and in all of these instances blood pressure (BP) was decreased after PTA. After a mean of 67 weeks, BP decreased from a systolic of 184 +/- 24 mm Hg pre-PTA to 135 +/- 15 mm Hg (P less than 0.001) and from a diastolic of 115 +/- 10 mm Hg pre-PTA to 87 +/- 11 mm Hg (P less than 0.001). The majority of patients continue to require antihypertensive drugs but in a less vigorous regimen than pre-PTA. Serum creatinine level fell following PTA from 1.9 +/- 0.6 to 1.7 +/- 0.5 mg/100 ml (P less than 0.01). Repeat angiographic study was done in nine patients, an average of 61 weeks after PTA, and no recurrent RTAS was identified. Three minor complications of PTA occurred but none led to long-term sequelae. Thus, we believe PTA of RTAS is relatively safe, carrying less mortality and morbidity than operative treatment, and is capable of improving BP control and renal allograft function.

Renal artery stenosis: anatomic classification for percutaneous transluminal angioplasty

Most lesions that decrease renal blood flow originate within the renal artery; however; large, aortic, atherosclerotic plaques can overhang the renal ostium producing a functional renal artery stenosis. At the Hospital of the University of Pennsylvania, 45 consecutive percutaneous transluminal angioplasties were examined retrospectively and classified as to site of the obstructing lesions and clinical outcome. Stenoses within the renal artery responded very well to angioplasty, with 83% of patients showing either an excellent or good result. Conversely, when aortic plaques were responsible for inflow obstruction, 76% of patients responded poorly or not at all to balloon dilatation. It is proposed that this disparity of response reflects the anatomic differences in the orientation of elastic and collagen fibers of the muscularis and advential layers of the renal artery and the aorta.

Factors associated with family planning acceptance in Bangkok metropolis health clinic areas (MHCs)

To study contraceptive use in Bangkok, 6,809 eligible women were interviewed in a community survey of 5 Metropolis areas. 34.7% were current users of interval contraception and the pill was the most common method. 29.9% were not currently in need of family planning. 18.3% of women were not using contraception, but only 6.2% were in need of family planning (FP) and not currently practising contraception. Non-acceptors who were in need of FP, had a lower educational level; 13.4% did not know about contraception but 52.4% previously used contraception. The most common reason for not currently practising FP was fears about contraceptive safety (37.5%). The prevalence of pregnancy in the community was 10.4%. The fact that only 6.2% of women were not practising FP and were in need of contraception suggests that the services in Bangkok are adequate to meet the needs of most women. However, the subgroup of non-acceptors in need of FP who were from a low socio-economic group require special motivation and services. 1,835 women attending Metropolis Health Centres in the same areas were interviewed to determine their choice of contraception; 57.4% chose the pill.