[Active management of labor and cesarean section rate].
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Cesarean Section↗
Biomedical subjects
B Kaplan
Publications and source records attributed to B Kaplan.
Wells' syndrome: report of a case and review of the literature.
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Adolescent↗
[Embryo transfer and multiple gestation--review of issues influencing the number of embryos transferred in in vitro fertilization and embryo transfer].
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Embryo Transfer↗
Role of increased basal expression of heat shock protein 72 in colonic epithelial c2BBE adenocarcinoma cells.
Although the expression of heat shock proteins (hsps) can be induced by a variety of stressful stimuli, certain neoplasms, including human intestinal T84, HT-29, and Caco2 adenocarcinoma cell lines, express constitutively high levels even under nonstress conditions. In this study, we examine the functional significance of increased hsp72 in spontaneously differentiating Caco2bbe (C2) cells. The expression of hsp72 in these cells was specifically inhibited by hsp72 antisense transfection. The loss of hsp72 expression did not affect growth rate, contact inhibition, morphological development, or functional differentiation. In contrast, these cells were significantly more sensitive to the injurious effects of oxidants and tumor necrosis factor (TNF) but not doxorubicin. To investigate potential mechanisms of action, a number of steps in the TNF-mediated cell death was measured. Antisense reduction of hsp72 did not alter activation of IkappaB. In contrast, mitochondrial cytochrome c release and activation of caspase 9 were significantly delayed in hsp72 antisense cells stimulated either with TNF or monochloramine. In conclusion, high endogenous expression of hsp72 by intestinal adenocarcinoma cells appears to confer selective survival advantage but does not affect their growth and differentiation.
Adenocarcinoma↗
Urinary incontinence in women: prevalence, characteristics and effect on quality of life. A primary care clinic study.
BACKGROUND: Urinary incontinence in older women is common. Its characteristics and impact on quality of life is not well established since these women are usually reluctant to tell their healthcare providers about the problem. OBJECTIVE: To determine the characteristics of urinary incontinence in women and the manner in which it affects patients' quality of life. METHODS: Twenty family physicians were requested to distribute a questionnaire to the first 25 consecutive women aged 30 to 75 years who visited their clinic for any reason. The questionnaire covered general health issues, symptoms of urinary incontinence, and quality of life. RESULTS: A total of 418 women, mean age 50.0 +/- 11.8 years, completed the questionnaire (84% response rate). Of these, 148 (36%) reported having episodes of urinary incontinence. Urinary incontinence was found to be associated with older age, menopause, obesity and coexisting chronic disorders. Sixty percent of the women with urinary incontinence found it to be a disturbing symptom, and 44% reported that it had a detrimental effect on their quality of life. Only 32% of the affected women had sought medical advice, half of them from their family physician. Treatment was recommended to 66% of those who sought help, and in about two-thirds of these it brought some measure of relief. CONCLUSIONS: Urinary incontinence is a common complaint among women attending primary care clinics, but it does not receive appropriate attention. Though it often adversely affects quality of life, only a small proportion of women seek medical advice. Family physicians should raise the issue as a part of the routine general health check-up.
Adult↗
Plasmapheresis treatment of recurrent FSGS in adult renal transplant recipients.
Plasmapheresis (PP) is often employed in the treatment of recurrent focal segmental glomerulosclerosis (FSGS) in the renal allograft, where it appears to be effective in the pediatric population. The efficacy of PP in adults and predictors of response are not well documented. We analyzed the records of 13 adult patients from three transplant centers who underwent PP for recurrent FSGS between 1993 and 1999. One patient (8%) had a complete response, one (8%) had a partial response, and 3 (23%) partially responded but remain PP-dependent. All 5 responders were started on PP within 30 days of recurrence, while 7 of the 8 non-responders initiated PP after a delay of at least 42 days (p = 0.0047). FSGS recurred within 30 days of transplantation in all 5 responders, while 4 of 8 non-responders had no evidence of recurrence until 42-150 days after transplantation (p = 0.098). Post-transplant biopsies were examined in 10 patients and revealed either cellular (6) or collapsing (4) variants of FSGS. We conclude PP is less effective in adults than in children as a treatment for recurrent FSGS in the renal allograft. Predictors of response to PP include early initiation of treatment after recurrence and possibly an early recurrence of disease.
Adult↗
Increased impact of acute rejection on chronic allograft failure in recent era.
BACKGROUND: Acute rejection (AR) remains a major risk factor for the development of chronic renal allograft failure (CAF), which is a major cause of late graft loss. With the introduction of several newer immunosuppressive agents (e.g., mycophenolate mofetil, tacrolimus and neoral) acute rejection rates have been steadily decreasing. However, the incidence of CAF has not decreased as dramatically as the incidence of acute rejection. One possible explanation is that the impact of AR on CAF is changing. The goal of this study was to analyze the relative impact of AR era on the development of CAF. METHODS: We evaluated 63,045 primary renal transplant recipients reported to the USRDS from 1988 to 1997. CAF was defined as graft loss after 6 months posttransplantation, censored for death, acute rejection, thrombosis, infection, surgical complications, or recurrent disease. A Cox proportional hazard model correcting for 15 possible confounding factors evaluated the relative impact of AR on CAF. The era effect (years 1988-1989, 1990-1991, 1992-1993, 1994-1995 and 1996-1997) was evaluated by an era versus AR interaction term. RESULTS: An AR episode within the first 6 months after transplantation was the most important risk factor for subsequent CAF (RR=2.4, CI 2.3-2.5). Compared with the reference group (1988-89 with no rejection), having an AR episode in 1988-89, 1990-1991, 1992-1993, 1994-1995, and 1996-1997, conferred a 1.67, 2.35, 3.4, 4.98 and 5.2-fold relative risk for the subsequent development of CAF (P<0.001). CONCLUSIONS: Independently of known confounding variables, the impact of AR on CAF has significantly increased from 1988 to 1997. This effect may in part explain the relative lack of improvements in long term renal allograft survival, despite a decline in AR rates.
Acute Disease↗
Relationship of recipient age and development of chronic allograft failure.
BACKGROUND: The elderly are the fastest growing segment of the end stage renal disease (ERSD) population. Older renal transplant recipients experience fewer acute rejection episodes than do younger patients. Despite this, death censored graft survival is no better in these older transplant recipients than in younger recipients. We examined the United States Renal Data System (USRDS) database to determine whether recipient age itself has an independent effect on the development of chronic allograft failure (CAF). METHODS: We analyzed 59,509 patients from the files of the USRDS. To determine whether age was an independent risk factor for CAF, the population was analyzed separately for Caucasians, African-Americans, and other ethnic groups. All renal transplant recipients from 1988 to 1997 were examined. Both univariate and multivariate analysis were performed using chronic allograft failure as the outcome of interest. RESULTS: Actuarial 8-year censored graft survival was significantly decreased in the older age groups 67% for ages 18-49 vs. 61.8% for ages 50-64 vs. 50.7% for ages 65+ (P<0.001). In the multivariate analysis, recipient age was a strong and independent risk factor for the development of chronic allograft failure in Caucasians (RR 1.29 for ages 50-64, RR 1.67 for ages older than 65). These findings were reinforced by an analysis that was restricted to living donor transplants without acute rejection. CONCLUSION: In Caucasians increased recipient age is an independent risk factor for the development of chronic renal allograft failure.
Adult↗
African-American renal transplant recipients experience decreased risk of death due to infection: possible implications for immunosuppressive strategies.
INTRODUCTION: African-American renal transplant recipients tend to experience more acute rejection episodes and have shorter graft survival than Caucasian renal transplant recipients. Various factors have been posited to be responsible for this difference, including relative under immunosuppression. We reasoned that by looking at the balance of acute rejections versus death due to infection, we could ascertain whether African-American renal recipients might have more reserve to tolerate an increase in pharmacological immunosuppression. METHODS: We analyzed the United States Renal Data System (USRDS) data from 1987 to 1997 regarding acute rejection episodes and infectious deaths. All other pertinent factors were gathered for a multivariate analysis. A total number of 68,885 adult renal transplant recipients were analyzed. RESULTS: When corrected for all covariates, the relative risk for acute rejection (1.3) was higher although the relative risk for infectious death was lower (0.7) in African-Americans as compared with Caucasians (P<0.01). CONCLUSION: Our study would indicate that relative to Caucasians, African-American renal transplant recipients are at decreased risk for infectious death and therefore may tolerate the more intensive immunosuppression that may be necessary to narrow the gap in acute rejection rates between African-Americans and Caucasian renal transplant recipients.
Adult↗
Initial results of solitary pancreas transplants performed without regard to donor/recipient HLA mismatching.
BACKGROUND: We hypothesized that solitary pancreas transplants could be performed successfully even in the presence of poor HLA matching if an aggressive approach were taken with regard to immunosuppressive protocol and the performance of allograft biopsy. METHODS: Seven pancreas-after-kidney transplants and seven pancreas transplants alone were performed without consideration given to the degree of HLA mismatching (MM) using tacrolimus (FK506)/mycophenolate mofetil (MMF)/prednisone maintenance therapy. Mean (+/-SD) total HLA MM was 4.8+/-1.2. All patients were followed for at least 6 months. The first four cases were induced with ATGAM for 7 to 10 days. In the remaining 10 cases, an ultrasound-guided percutaneous needle biopsy was attempted on a protocol basis 10 days after completing induction with OKT3 for 7 (n=2) or 14 (n=8) days. RESULTS: Overall patient survival, graft survival, and incidence of acute rejection requiring treatment were 86, 79, and 50%, respectively. Two patients receiving ATGAM developed grade III-IV rejection at 3 weeks. Both patients receiving OKT3 for 7 days developed early grade III rejection. However, only three of eight patients receiving OKT3 for 14 days developed rejection requiring treatment. Protocol biopsy was successfully performed in six of seven patients and uncovered three cases of otherwise undetectable grade III-IV rejection. CONCLUSIONS: Although based on a small number of cases, our results suggest that solitary pancreas transplants with a poor HLA match can be performed with an acceptable rejection incidence and graft survival rate using an OKT3/FK506/MMF/prednisone regimen with protocol biopsy.
Adolescent↗
Excellent outcome of renal transplantation in patients with Fabry's disease.
INTRODUCTION: Fabry's disease is an X-linked error of glycosphingolipid metabolism. Clinical manifestations of the disease are secondary to accumulation of glycosphingolipids in various tissues. Renal failure and vascular complications are common. There are conflicting reports regarding the outcomes of patients with Fabry's disease after renal transplantation. METHODS: We reviewed the United States Renal Data System Registry database from 1988 and 1998, and found 93 patients with Fabry's disease who had received a renal transplant. Case-matched patients were identified to serve as controls. RESULTS: Patients with Fabry's disease demonstrated equivalent 5-year patient and graft survival, compared with controls (83% and 75%, respectively, for those with Fabry's disease vs. 82% and 67% for controls). CONCLUSION: Despite their high risk for cardiovascular complications, patients with Fabry's disease have excellent outcomes after renal transplantation.
Adult↗
Mycophenolate mofetil reduces late renal allograft loss independent of acute rejection.
BACKGROUND: Mycophenolate Mofetil (MMF) has been shown to significantly decrease the number of acute rejection episodes in renal transplant recipients during the 1st year. A beneficial effect of MMF on long-term graft survival has been more difficult to demonstrate. This beneficial effect has not been detected, despite the impact of acute rejection on the development of chronic allograft nephropathy and experimental evidence that MMF may have a salutary effect on chronic allograft nephropathy independent of that of rejection. METHODS: Data on 66,774 renal transplant recipients from the U.S. renal transplant scientific registry were analyzed. Patients who received a solitary renal transplant between October 1, 1988 and June 30, 1997 were studied. The Cox proportional hazard regression was used to estimate relevant risk factors. Kaplan-Meier analysis was performed for censored graft survival. RESULTS: MMF decreased the relative risk for development of chronic allograft failure (CAF) by 27% (risk ratio [RR] 0.73, P<0.001). This effect was independent of its outcome on acute rejection. Censored graft survival using MMF versus azathioprine was significantly improved by Kaplan-Meier analysis at 4 years (85.61% v. 81.9%). The effect of an acute rejection episode on the risk of developing CAF seems to be increasing over time (RR=1.9, 1988-91; RR=2.9, 1992-94; RR=3.7, 1995-97). CONCLUSION: MMF therapy decreases the risk of developing CAF. This improvement is only partly caused by the decrease in the incidence of acute rejection observed with MMF; but, is also caused by an effect independent of acute rejection.
Acute Disease↗
Nephrogenic adenomas occurring in a patient with simultaneous kidney-pancreas transplant.
We present a female patient who developed multiple nephrogenic adenomas of the bladder about 3 years after a simultaneous kidney-pancreas transplant. The patient was initially treated with endoscopic resection but, due to recurrences, she later underwent a conversion of pancreatic drainage from the bladder to the small bowel and has since done well. We believe this to be the first such case reported in the literature.
Adenoma↗
Allograft loss in renal transplant recipients with Fabry's disease and activated protein C resistance.
INTRODUCTION: Fabry's disease is associated with an increased incidence of thrombotic events and rejection. Spontaneous thrombosis of a functioning cadaveric renal allograft in a recipient with Fabry's disease prompted prospective evaluation of all transplant candidates with Fabry's disease for hypercoagulability. MATERIALS AND METHODS: Transplant candidates with Fabry's disease were tested for hypercoagulability, analyzed for HLA-type and ABO group, and comorbid conditions suggestive of hypercoagulability. RESULTS: A unique association of Fabry's disease with activated protein C Resistance was documented in a cohort of Caucasian male renal transplant recipients with Fabry's disease. Four of five patients were blood group A and had no significant comorbid conditions suggestive of hypercoagulability. The resistance to activation of protein C (APCR)(+) patients shared HLA loci-B8 and Dr3, although the APCR(-) patients shared HLA loci-B27 and -B38. CONCLUSIONS: Due to the observed increase in the incidence of APCR in our Fabry's cohort, we suggest screening all patients with Fabry's disease for APCR. Because factor V and factor Va receptors are found on vascular endothelium and peripheral blood monocytes, APCR in the presence of Fabry's disease may be a nonimmunological stimulus for rejection. Analysis of HLA typing in patients with Fabry's disease may further elucidate HLA-based association of Fabry's disease and resistance to activated protein C with the risk of thrombosis and rejection.
ABO Blood-Group System↗
[Dysfunctional uterine bleeding--etiology, mechanism, management and treatment].
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Female↗
Withdrawal of mycophenolate mofetil in stable renal transplant recipients.
BACKGROUND: Mycophenolate mofetil (MMF) has been demonstrated to decrease episodes of acute rejection in renal transplant recipients during the first year after transplantation. The utility of MMF after 1 year is less clear. METHODS: Forty-five stable renal transplant recipients on maintenance therapy of cyclosporine microemulsion, MMF, and prednisone had MMF withdrawn at approximately 1 year after transplantation. A matching concurrent group of 45 stable renal transplant recipients served as the case control group. RESULTS: Two of 45 patients in the MMF withdrawal group suffered an acute rejection episode as opposed to 1 of 45 in the control group. Both patients who rejected in the withdrawal group had adequate cyclosporine levels and had no recent decrease in prednisone dose. There was no evidence of an increased incidence of proteinuria or increased creatinine levels in the MMF withdrawal group. CONCLUSION: In general, withdrawal of MMF in stable renal transplant recipients is well tolerated. No increased risk of rejection could be demonstrated in this patient group. A larger study will be needed to confirm our result.
Adult↗
Unmasking of primary hyperaldosteronism by renal transplantation.
BACKGROUND: Primary hyperaldosteronism is an uncommon cause of hypertension in the general population. Given the mechanism of action of aldosterone clinical manifestations may not occur in the setting of end stage renal disease. However, if a successful renal transplant is performed clinical manifestations may occur. METHODS: We present a case of a patient with a preexisting adrenal adenoma who only presented with clinical signs of hyperaldosteronism after renal transplantation. Patients' work-up included plasma aldosterone, plasma renin activity, serum cortisol, and estimation of trans tubular potassium gradient. RESULTS: The patient's serum aldosterone was markedly elevated with a relatively suppressed plasma renin activity. Trans tubular potassium gradient was high in the presence of hypokalemia. CONCLUSION: Previously silent hyperaldosteronism may be unmasked by a successful renal transplant.
Adenoma↗