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D A Goldfarb

Publications and source records attributed to D A Goldfarb.

At least 37 records · Page 2Linked to original sources
PubMed1998

Nephron-sparing surgery and renal transplantation in patients with renal cell carcinoma and von Hippel-Lindau disease.

Renal cell carcinoma is a common manifestation of von Hippel-Lindau disease and an important cause of mortality in these patients. A contemporary approach to the treatment of localized renal cell carcinoma is outlined based upon several recently conducted multicentre reviews. When technically feasible nephron-sparing surgery can preserve renal function without compromising long-term survival in most patients. For those who develop end-stage renal failure as a result of treatment for renal cell carcinoma, excellent results with a limited risk for development of recurrence can be obtained with renal transplantation.

Carcinoma, Renal Cell↗
PubMed1997

Results of renal transplantation in patients with renal cell carcinoma and von Hippel-Lindau disease.

BACKGROUND: Patients with von Hippel-Lindau (VHL) disease are at risk for the development of end-stage renal failure from the treatment of localized renal cell carcinoma. Transplantation with its attendant immunosuppression may predispose patients to tumor recurrence; however, there is little information regarding the outcome with this approach. In this article, we review the North American and European experience with renal transplantation in this patient population. METHODS: The study group comprises 32 patients who have VHL rendered anephric secondary to localized renal cell carcinoma and who have undergone renal transplantation. Patients were identified from North American (n=18) and European (n=14) registries. The outcome of the study group is compared with a cohort of 32 renal transplant recipients without VHL from the Cleveland Clinic Unified Transplant Data Base, who were matched for donor source, gender, age, transplant status (primary vs. regraft), and date of transplantation. RESULTS: The 23 men and 9 women in the study group received transplants between 1974 and 1996. The average age at transplantation was 36 years, and the average duration of dialysis before transplantation was 26 months. Patients have been followed for 48+/-35 months. There was no statistically significant difference in graft survival, patient survival, or renal function between the study and control groups. There were five deaths in both the study and control groups. In the study group, three patients died with metastatic disease. There was no difference in the duration of dialysis before transplantation between patients who developed metastatic disease and those who did not. CONCLUSION: These data support the utility of renal transplantation as an effective form of renal replacement therapy in this unique population, with a limited risk of recurrent cancer.

Carcinoma, Renal Cell↗
PubMed1997

Should obese patients lose weight before receiving a kidney transplant?

BACKGROUND: The results of renal transplantation in obese recipients have been controversial, with some reports finding increased morbidity prohibitive and others finding increased morbidity acceptable. We attempted to determine whether obese patients in extreme excess of their ideal body weight should undergo transplantation. METHODS: The study population included 127 obese (body mass index >30 kg/m2) patients who were compared with a matched nonobese control group (body mass index <27 kg/m2) of 127 recipients with similar demographics. There were no significant differences between the groups according to donor source, recipient race or sex, retransplants, transplant percent reactive antibodies, cause of renal failure, or hypertension. However, significantly more obese patients had a pretransplant history of angina (11.2% vs. 3.2%, P=0.02) or a previous myocardial infarction (5.6% vs. 0.8%, P=0.04). RESULTS: The mean follow-up was 58.9+/-40 (range 3-170) months. Nonobese patients enjoyed a significantly (P=0.0002) greater patient survival (89% vs. 67%) at 5 years and suffered only about half the number of deaths (25 vs. 46) during the period of observation. Cardiac disease was the leading cause of death (39.1%) in the obese group. Patient death had a major impact on graft survival because there were no differences between the groups when death with graft function was censored from the analysis. There were no significant differences between the groups in delayed graft function, acute rejection, chronic rejection, length of hospital stay, operative blood loss, or mean serum creatinine up to 5 years. However, obese patients experienced significantly (P=0.0001) more complications per patient (3.3 vs. 2.2) and a greater incidence (P=0.0003) of posttransplant diabetes (12% vs. 2%). Similar cyclosporine blood levels were observed in obese recipients even though they were receiving 0.75-2 mg/kg/day less cyclosporine than the nonobese recipients. CONCLUSIONS: Outcome differences in obese renal transplant patients were primarily due to a higher mortality resulting from cardiac events. Obesity seems to have little effect on immunologic events, long-term graft function, or cyclosporine delivery. Aggressive pretransplant screening for ischemic heart disease is essential to identify an especially high-risk subgroup of obese patients. Although it would seem prudent to recommend weight reduction <30 kg/m2 to all patients before transplant, these data suggest that obese patients with a history of cardiac disease should not be transplanted until weight reduction has been accomplished.

Adult↗
PubMed1997

Cleveland Clinic experience with adrenal Cushing's syndrome.

PURPOSE: Cushing's syndrome due to adrenal adenoma or adrenocortical carcinoma is rare. To understand better the clinical and biochemical presentation of this disorder, as well as therapy efficacy and patient survival, we conducted a retrospective review. MATERIALS AND METHODS: Between August 1971 and April 1994, 40 patients presented to our institution with adrenal Cushing's syndrome (27 adenomas and 13 carcinomas). These groups were analyzed with respect to clinical signs and symptoms preoperatively and postoperatively, biochemical analysis, length of postoperative steroid replacement therapy, disease recurrence and patient survival. Followup was obtained by chart review and telephone interviews and averaged 59.6 +/- 66.4 and 47.6 +/- 56.2 months for adenoma and carcinoma patients, respectively. RESULTS: Women predominated in both groups (26 of 27 adenomas, 11 of 13 carcinomas), and tumors affected the left adrenal gland more frequently (19 of 27 adenomas, 9 of 13 carcinomas). Adenoma patients were younger than carcinoma patients (39.6 +/- 14.4 versus 51.5 +/- 16.6 years, p = 0.026) and presented with smaller tumors (3.3 +/- 1.0 versus 8.6 +/- 4.5 cm., p = 0.001). There was a trend toward increased incidence of glucose intolerance among carcinoma patients but no significant differences in clinical signs or symptoms between adenoma and carcinoma patients could be made. Similarly, while there was no significant difference in biochemical evaluation of adenoma versus carcinoma patients, 24-hour urinary free cortisol and serum lactate dehydrogenase levels tended to be higher among carcinoma patients. In addition 17-ketosteroid and dehydroepiandrosterone sulfate levels were more elevated in carcinoma than in adenoma patients, and several adenoma patients actually had subnormal levels. Among adenoma patients mean length of steroid replacement therapy was 16.8 +/- 9.1 months. However, 7 adenoma patients (25.9%) required greater than 24 months of exogenous steroids, and only 1 of these patients was subsequently weaned off steroid replacement. There were no recurrences among adenoma patients, although there was 1 perioperative death due to hypoglycemia. Ten (76.9%) carcinoma patients had recurrences at a mean followup of 33 months. The 3 and 5-year survival rates were 41.5 and 31.2%, respectively. CONCLUSIONS: While presenting signs and symptoms and hormonal analysis may suggest benign or malignant disease, only tumor size and patient age are reliable preoperative indicators of adrenal adenoma versus adrenocortical carcinoma among patients with adrenal Cushing's syndrome. Surgery is curative for adenoma patients, but lifelong steroid replacement may be required. Survival remains poor among carcinoma patients.

Adrenal Cortex Neoplasms↗
PubMed1997

The use of kidneys from living donors with renal vascular disease: expanding the donor pool.

PURPOSE: The disparity between the number of patients awaiting organ transplantation and the number of available donor organs continues to increase. We report the outcomes of transplantation using kidneys from living donors who had unilateral renovascular disease. MATERIALS AND METHODS: We identified 5 living donors who had unilateral renovascular disease, including saccular renal artery aneurysms, an arteriovenous malformation, localized atherosclerosis and fibromuscular renal artery stenosis. Each donor was normotensive and asymptomatic, and had otherwise normal renal function. RESULTS: In each case the abnormal kidney was removed, the lesion was repaired ex vivo and the kidney was successfully transplanted without complication in the donor or recipient. Each recipient had a serum creatinine of less than 2 mg./dl. and each donor remained normotensive with stable renal function at up to 3 years of followup. CONCLUSIONS: Kidneys from living donors with renovascular disease can be transplanted safely provided that careful selection, informed consent and a normal remaining kidney are ensured.

Adult↗
PubMed1996

Determinants of chronic renal allograft rejection in cyclosporine-treated recipients.

We analyzed the development of chronic rejection in 511 kidney-only renal transplants in 507 patients between July 1987 and November 1994. A database was established for recipients > or = 18 years old who received cyclosporine-based immunosuppression and demonstrated graft survival for a minimum of 12 months. The 347 recipients of cadaver transplants (67.9%) and 164 recipients of live donor transplants (32.1%) were followed for 12 to 102 months (mean 51 months). Chronic rejection was diagnosed in 124 transplants (24%), with a mean time to diagnosis of 23+/-18 months (range 3-92). Risk factors were identified in a multivariate analysis using the Cox model. The impact of the timing and severity of rejection episodes was analyzed in a univariate model. The presence of chronic rejection resulted in decreased (P=0.0001) 5-year graft survival for both cadaver graft (83.7% vs. 58.2%) and live donor graft (93.2% vs. 53.1%) recipients. Significant variables for the development of chronic rejection included an acute rejection episode (P=0.0001), a black recipient (P=0.0006), donor age > or = 50 years (P=0.006), and a serum creatinine level >2.0 mg/dl by 6 months after transplantation. Severity of rejection measured by peak serum creatinine or posttreatment return to baseline was not related to chronic rejection. However, acute rejection episodes lasting for more that 5 days (P=0.03) or occurring after 6 months (P=0.001) did influence time to chronic rejection. In addition, mismatching for donor-recipient race was a significant (P=0.008) risk factor for recipients of cadaver grafts. We conclude that acute rejection is the most significant risk factor for chronic rejection, and the long-term fate of grafts may be determined as early as the first 6 months. Racial matching of donor-recipient pairs may be useful to minimize chronic rejection risk. Future advances that diminish the incidence and severity of acute rejection may have the greatest impact on long-term survival.

Acute Disease↗
PubMed1995

Transperitoneal marsupialization of lymphoceles: a comparison of laparoscopic and open techniques.

This 2-center study compares the relative merits of laparoscopic and open surgical internal marsupialization of pelvic lymphoceles. Laparoscopic lymphocelectomy was performed in 12 patients (group 1). The results were compared with open lymphocelectomy performed in 13 contemporary patients (group 2) as well as 13 historical patients (group 3). Operative time was longer in group 1 compared to groups 2 and 3 (194.6 versus 176.9 versus 133.8 minutes, respectively). However, group 1 had a decreased blood loss (23.1 versus 74.6 versus 61.7 ml.), earlier resumption of oral food intake (0.9 versus 2.5 versus 2.1 days), shorter hospital stay (2 versus 6.1 versus 6.3 days) and abbreviated convalescence (2.2 versus 6.9 versus 4.5 weeks) compared to groups 2 and 3. Complications included cystotomy requiring open repair in 1 patient in group 1, prolonged ileus in 1 in group 2, transection of the ureter of a transplant kidney in 1 in group 3 and pneumonitis in 1 in group 3. Lymphocele recurred in no patient in group 1, 4 in group 2 and 3 in group 3. Mean followup in groups 1 to 3 was 12.8, 25 and 54.5 months, respectively. We conclude that laparoscopic lymphocelectomy is effective, results in minimal patient morbidity and allows for a more rapid recovery compared to open surgical lymphocelectomy.

Adult↗
PubMed1995

Preservation of renal function and the risk of hyperfiltration nephropathy.

The long-term impact of unilateral nephrectomy on renal function has been reviewed in patients who have undergone donor nephrectomy or nephrectomy in childhood as a result of unilateral renal disease. there has been no adverse impact on renal function. In the setting of a normal contralateral kidney, and in the absence of any urologic or systemic disorder that may affect future renal function, it is not necessary to perform nephron-sparing surgery for the purpose of preservation of renal function.

Adolescent↗
PubMed1995

Changing demographics in renal transplant recipients: the 30 year Cleveland Clinic experience.

While it does appear that the most recent era of transplantation has not resulted in significant improvement in long-term allograft function, this appears to be due, at least in part, to the transplantation of increasing numbers of high-risk patients. It is noted that the improved results accomplished over prior eras of transplantation have been maintained despite the inclusion of these high-risk patients. Patients currently undergoing transplantation are more likely to be older, diabetic, obese or African American. All of these subgroups have poorer patient survival in the most recent transplant era and thus, death with a functioning graft has become a significant contributor to graft loss. Recipients were more likely to receive kidneys from cadaveric donors in the most recent era and within the live-donor groups, sibling donation has decreased. Hopefully, the recent trend of increased live-donor transplants (especially living, unrelated transplants) will continue. Cadaveric recipients were at higher risk for posttransplant ATN which, for the first time in the current era, had a significant adverse impact on graft survival. Long-term survival appeared to be associated with particular characteristics (optimal age at transplantation, optimal donor age, live donor, etc.), and can be achieved despite known risk factors, such as rejection or delayed graft function.

Adolescent↗
PubMed1994

Management of atherosclerotic renal artery disease in younger patients.

From 1970 to 1990, 57 patients 50 years old or younger were treated for hypertension caused by atherosclerotic renal artery disease. Predisposing factors for atherosclerosis included smoking in 43 cases, hyperlipidemia in 15, diabetes in 8 and hyperuricemia in 8. Of the patients 47 had a family history of atherosclerotic vascular disease or a significant related disorder. Evidence of generalized atherosclerosis was present in 55 patients. Atherosclerotic renal artery disease was present unilaterally in 16 cases, bilaterally in 39 and in a solitary kidney in 2. Of the patients 34 were treated surgically, 20 medically and 2 by percutaneous angioplasty. Surgically treated patients experienced significant postoperative improvement in blood pressure (p = 0.001) and renal function (p = 0.05). Medically treated patients experienced significant improvement in blood pressure (p = 0.03) but renal function deteriorated. Younger patients with atherosclerotic renal artery disease suffer from a more severe and accelerated form of atherosclerosis than older patients. Although blood pressure control can be achieved with medical treatment, surgical revascularization offers the best opportunity for stabilization or improvement of renal function.

Adult↗
PubMed1994

Angiotensin II receptor subtypes in the human renal cortex and renal cell carcinoma.

Selective antagonists were used to determine the presence of angiotensin II (Ang II) receptor subtypes (AT1 and AT2) in normal human renal cortex and renal cell carcinoma. Normal and tumor tissues were obtained from fresh radical nephrectomy specimens in 7 patients. All patients had a patent renal artery, and the mean preoperative serum creatinine level was 1.1 mg./dl. Tissues were snap frozen and sectioned (14 microns.) for in vitro autoradiography, then incubated in 125I-Ang II (0.3 nM.), with or without unlabeled Ang II or subtype selective antagonists (1 nM. to 1 microM.), rinsed, air dried and apposed to SB-5 X-ray film for 3 to 21 days. In normal renal tissue, low densities of diffuse 125I-Ang II binding sites were observed in cortical areas containing tubules. Higher densities of binding sites occurred over glomeruli and large cortical vessels. Specific binding ranged between 60 and 90% depending on the area as determined by displacement with excess unlabeled Ang II. Specific binding in large cortical vessels was displaced by the two AT2 selective antagonists PD123177 (1 microM.) or CGP 42112A (0.01 microM.), whereas these antagonists were less effective competitors for 125I-Ang II binding in glomeruli. In contrast, the AT1 selective antagonists, DuP 753 and L-158,809 (0.1 and .01 microM., respectively), were potent competitors for glomerular, but not extraglomerular, cortical vessel binding. In the normal cortical tubulointerstitium, both AT1 and AT2 antagonists caused partial displacement of specific binding (55 +/- 12% AT1, 39 +/- 12% AT2). Low density 125I-Ang II binding was present in all tumors. Specific binding averaged 59 +/- 10% as defined by displacement with unlabeled Ang II (1 microM.). As in the normal tubulointerstitial area, each of the selective antagonists produced partial displacement of the specific binding (60 +/- 12% AT1, 31 +/- 8% AT2). In conclusion, AT1 receptors predominate in glomeruli, while AT2 binding sites predominate in large preglomerular vessels of the human renal cortex. In the normal tubulointerstitium and renal cell carcinoma, a 60%/40% mixture of AT1 to AT2 receptors exists. These findings provide a pharmacologic framework for the differential effects of Ang II receptor-mediated function in the human kidney.

Angiotensin II↗
PubMed1994

Safety of transurethral surgery in the early postoperative period following an open cardiac procedure.

A retrospective investigation was performed to determine whether patients undergoing transurethral surgery soon after cardiac surgery experienced increased morbidity or mortality rates. From 1986 to 1990, 24 patients first underwent open heart surgery and then either transurethral prostatectomy, bladder tumor resection or bladder cup biopsy during the same hospital stay. Postoperative complications included significant hematuria in 2 patients (8%), mild stress incontinence in 1 (4%) and bladder perforation in 1. One patient died of a spontaneous pneumothorax 17 days after the urological operation. None of these patients had had a previous myocardial infarction. The outcome of these patients was compared to that of 115 men who underwent transurethral prostatectomy for presumed benign disease during 1990. Complications of transurethral prostatectomy in this group included significant gross hematuria in 5 men, while 6 experienced urinary retention (1), atrial fibrillation (1), delirium (1), myocardial infarction (1), seizure (1) and intraoperative urethral injury (1). There was 1 death from multiple postoperative complications. Morbidity and mortality rates did not differ significantly between the 2 groups. Transurethral surgery performed after cardiac surgery during the same hospital stay appears to be safe, provided the patient is stable.

Aged↗
PubMed1994

The renin-angiotensin system. New concepts in regulation of blood pressure and renal function.

The past decade has been considerable advances in basic knowledge of the renin-angiotensin system. Perhaps the most important new development has been the appreciation of a tissue-based renin-angiotensin system that can be independently regulated from the circulation. Greater insight into the mechanism by which the renin-angiotensin system exerts its actions has been achieved through the study of molecular biology and pharmacologic characterization of multiple angiotensin receptor subtypes. Ang II is now considered a growth promoter in cardiovascular tissues, and the resultant vascular hypertrophy is an important contributor to the maintenance of hypertension. Ang II also plays a role in the kidney, not only as a regulator of hemodynamics, but in the development of structural changes (hypertrophy, sclerosis), which are important in the pathogenesis of a variety of renal disorders. Finally, a central role for the renin-angiotensin system in experimental renovascular hypertension has been reaffirmed. In the future, basic knowledge and techniques of investigation gained from experimental models will be used to investigate clinical disorders such as hypertension and various renal disorders characterized by abnormal function of the renin-angiotensin system.

Animals↗