Biomedical subjects
Publications and source records attributed to G Kootstra.
The subject of ectopic adrenal tissue along the spermatic cord is reviewed in respect of incidental finding during operation for undescended testis. The condition is probably more common than previously reported and embryology and clinical implications are briefly discussed. Nodules consisting of aberrant adrenal tissue should be removed whenever incidentally detected, but a routine search for them is not mandatory.
Successful 6-day kidney preservation was obtained with a combination of perfusion techniques. Canine kidneys were preserved by hypothermic continuous perfusion in a Gambro machine with albumin perfusate. On day 3 the hypothermic preservation was interrupted by a normothermic perfusion for 3 hr. This intermediate perfusion was performed in a heart-lung machine filled with heparinized blood from non-related dogs. The preserved kidneys were autotransplanted in subsequently nephrectomized dogs. Nine of 11 animals with such preserved kidneys survived in a healthy condition. In the control group with hypothermic perfusion only, one of 8 dogs survived after implantation. In this dog a high serum creatinine concentration was measured after implantation. Kidney function was assessed by determining glomerular filtration rate (GFR), effective renal plasma flow (ERPF), and filtration fraction (FF) during the intermediate blood perfusion in the experimental group and at 1 hr after implantation in both groups. A low FF (less than 0.27) indicated the presence of active functioning tubules in the intermediate blood-perfused group. In this group the GFR, ERPF, and FF values returned to normal within 10 days after implantation. These results show that it is possible to prevent irreversible preservation damage by normothermic blood perfusion. Histological observation indicated that the isolated blood perfusion had a beneficial effect, especially on the tubules of the preserved kidney.
Data are presented on the ability of arterial and venous endothelial cells to stimulate allogeneic leukocytes. Mixed cultures of allogeneic endothelium and lymphocytes result in proliferation of lymphocytes and generation of cell-mediated cytotoxicity, which do not occur in cultures of syngeneic combinations of endothelium and lymphocytes. Studies of kinetics showed a peak in proliferation at days 6-7. The optimal responder-stimulator ratio appeared to be 15:1. Lymphocytes stimulated with venous endothelial cells were cytotoxic both for arterial and for venous endothelial cells and PHA blasts of the stimulator dog, whereas lymphocytes stimulated with arterial endothelial cells lysed only arterial endothelial cells and PHA blasts of the stimulator. Lysis of syngeneic or third-party allogeneic control targets was virtually absent. Optimal conditions for long-term culture of effector cells from mixed leukocyte endothelial cell cultures were analyzed. Addition of Il 2 every 3 days and the original stimulating antigen every 6 days permitted continuous proliferation of these cytotoxic lymphocytes with preservation of the cytotoxicity pattern.
Alloantigen-specific cytotoxic T lymphocytes (CTL) and their precursors (CTL-P) have been determined in the peripheral blood of skin allografted dogs. CTL-P frequencies increased rapidly after transplantation and reached maximal values after complete rejection of the skin allograft. Differences in the time response kinetics of CTL-P frequencies between recipients were not correlated with the length of graft survival. The CTL-P frequencies declined after days 13-20 and appeared still to be elevated 30 days after rejection of the graft.
Cellular cytotoxicity generated in vitro has been studied with canine T and B lymphoblasts as target cells. B lymphocytes were isolated by rosetting with protein A labeled sheep red blood cells and stimulated with sepharose bound protein A. Such highly purified stimulated B lymphoblasts appeared to be useful target cells for cellular cytotoxicity. Cold target inhibition studies and limiting dilution analysis revealed that B lymphocytes did not carry targets for cytotoxic T lymphocytes (CTL) which were not present on PHA stimulated T lymphoblasts.
The influence of warm and cold ischemic time (WIT and CIT) on renal allograft function and allograft survival rates was analyzed from the Eurotransplant data. From 1977 through 1980 renal allograft recipients were divided into three groups, according to the length of the WIT of their graft: group I, 0-10 min (n = 2,636); group II, 11-20 min (n = 108); group III, 21-35 min (n = 17). Differences in graft function or graft survival have not been observed between these groups. It is concluded that donor kidneys with a WIT up to 20 min are acceptable for transplantation. The transplantation results in group III suggest that 35 min is a safe limit for acceptance, but the small number of transplantations in this group does not justify a firm conclusion. A combined analysis of warm and cold ischemia shows that simple cold storage up to 50 h is safe and acceptable, provided that warm ischemia is kept minimal (less than 10 min). It seems advisable to keep hypothermic preservation within the limit of 30 h, when WIT exceeds 10 min.
Transplantation results after kidney preservation by means of cold storage and machine perfusion were analyzed. Graft survival and function of 75 machine-perfused kidneys were the same as those of 2,686 kidneys preserved by cold storage. Cold storage, a relatively simple, safe, and inexpensive procedure, was preferred for the preservation of kidneys that had not been subjected to prolonged periods of warm ischemia. Machine perfusion could be used for kidneys damaged by ischemia, although its advantage over cold storage in these circumstances was not firmly established.
A three-day-old newborn developed necrotizing enterocolitis in absence of the usual precipitating factors. Colonic perforation necessitated surgical intervention. After recovery cow's milk allergy was diagnosed. Probably this food allergy was the cause of the development of the necrotizing enterocolitis.
Continuous hypothermic perfusion (CHP) was improved when interrupted by an interval of ex vivo perfusion. The influence of the length (1-4 hr) of this interval of ex vivo perfusion was studied in a dog model. Kidneys were subjected to CHP for 72 hr, then connected with the donor for 1, 2, 3, and 4 hr, then returned to CHP and, after a total preservation time of 144 hr, autotransplanted. Simultaneous contralateral nephrectomy was performed. Life-sustaining kidney function was obtained in all of the 6 animals in the 3-hr group and in 5 of the 6 in the 4-hr group. Shorter ex vivo perfusion intervals (1-hr and 2-hr) resulted in no survivors and 2 survivors out of 6, respectively. Creatinine levels of animals that received autotransplants of 3-hr and 4-hr ex vivo perfused kidneys returned to near normal values within 10 days after transplantation.
A method is described which permits culture of both arterial and venous canine endothelial cells. Cell-mediated cytotoxicity against cultured endothelial cells has been studied. A 51Cr-release assay was used to detect CTL generated in MLC. Both arterial and venous endothelial cells are lysed by CTL specifically. Cold target inhibition experiments have been performed to analyse the CTL-recognized antigens on arterial and venous endothelial cells. Different antigens are recognized by CTL on venous endothelial cells and PHA-blasts; it is possible that CTL recognize venous endothelial cells through class II antigens or E-M antigens. Arterial endothelial cells and PHA-blasts share CTL-recognized antigens.
It is current practice to only consider heart-beating donors as suitable for organ donation. Patients who have sustained a permanent cardiac arrest are believed to be unsuitable for kidney retrieval, in the knowledge that the kidneys will have received extensive ischemic damage. In situ kidney preservation (ISP), using the double balloon triple lumen (DBTL) catheter, offers the possibility of harvesting valuable kidneys from these, otherwise unsuitable, donors. With this technique human kidneys can be cooled in situ prior to the donor nephrectomy. During ISP, nephrectomy can be performed under optimal surgical conditions. In this report indications for ISP, insertion technique of the DBTL catheter, legal aspects, and transplantation outcome of kidneys harvested by means of ISP are discussed.
Patients with generalized peritonitis form a rather threatened group, with a high mortality and risk of complications which increases when multiple organ failure develops. In 20 patients with this condition, the laparotomy wound was closed without tension using a Marlex mesh prosthesis, after surgical treatment of the underlying illness and drainage of the abdominal cavity. The mortality was lower than expected, according to data from the literature; also, pulmonary complications, residual abscesses and wound dehiscence occurred less frequently. This method seems to be a valuable contribution to the complex treatment of these patients.
There is a progressive increase of patients in the dialysis population in whom primary access by a Brescia-Cimino A-V fistula is no longer possible. These patients require secondary access procedures. Instead of using graft material several alternatives exist using the patient's own venous and arterial remnants, as morbidity and mortality of these procedures will be less than those where graft material is used. Long term patency rates of graft fistulae are disappointing, partially due to the damage to the graft by repeated punctures. A new device, which avoids needling, is briefly mentioned.
The surgical removal of a transplanted kidney following rejection or failure can be hazardous. A total of 110 grafts were removed consecutively in 84 patients (in 21 cases a second graft and in 5 cases a third graft was removed). Two surgical techniques were applied: extracapsular and intracapsular removal. The extracapsular technique was associated with complications in 11 out of 69 cases (16 per cent) and the intracapsular technique, in 3 out of 36 cases (8 per cent). In 5 cases the operative technique could not be determined from the records. In the 14 cases developing complications, wound infection was observed in 7 cases, wound haematoma in 4 and mycotic aneurysm, pulmonary embolism and clotting in the bladder each in 1 case. One patient (1.2 per cent) died due to late complications after allograft nephrectomy following rupture of a mycotic aortic aneurysm. The technique of kidney transplant removal by either the intra- or extra-capsular route of the exact timing of the operation are important features for safe treatment of patients with end-stage graft failure.
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In 2 groups of 6 dogs each the right kidney was removed, flushed with Collins and then perfused in a Gambro preservation machine for 6 days. After this period the kidneys were reimplanted in the neck of the subsequently nephrectomized donor. The only difference in Group 2 was that halfway the 6-day hypothermic perfusion the kidneys were taken from the machine and perfused ex vivo for 3 hours by connections with the femoral vessels of the same donor dog. After implantation, only 1 dog from group 1 survived. All 6 dogs in group 2 survived. A low filtration fraction (less than 0.26) after implantation, measured 1 hour after implantation, correlated well with and predicted life sustaining kidney function. During the ex vivo perfusion in group 2, an improving proximal tubular secretion and water reabsorption was observed.
The case histories of seven children with prehepatic portal hypertension are presented. An umbilical vein catheter was introduced in six of the seven patients during the neonatal period for administration of fluids, including hypertonic and alkaline solutions. There appears to be a relationship between umbilical vein catheterization and thrombosis of the portal system. The methods of treating this condition are controversial. The most important sign is bleeding from oesophageal varices. Elective portosystemic shunts give the best operative results. A conservative policy, however, does not appear to have a higher mortality and probably results in a lower morbidity. Our present management is therefore conservative.
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