Biomedical subjects
Publications and source records attributed to H Zincke.
2 patients underwent saphenous vein-coronary artery bypass grafting before successful renal transplantation. Both patients were able to undergo appropriate therapy for various complications, which further emphasizes the resilience that these patients can have after adequate coronary revascularization.
Sixty-one patients with end-stage renal failure due to diabetic nephropathy received 68 renal allografts from June 1970 to February 1978. Patient and graft survival results equaled those for nondiabetic patients, as reported by the Human Renal Transplant Registry (HRTR). Renal allografts from siblings or pretreated cadaver donors had a significantly longer survival time than did allografts from nonpretreated cadaver donors. It is concluded that renal transplantation with living related and pretreated cadaver donor kidneys continues to be the treatment of choice and is superior to other forms of treatment in the insulin-dependent diabetic patient with end-stage renal disease.
Six patients (five men and one woman) with Alport's syndrome underwent successful renal transplantation (four received kidneys from cadaver donors and two received allografts from living, related donors). One patient who had received a cadaver kidney had substantial hearing improvement and the others had stabilization of hearing. Hearing loss in Alport's syndrome is progressive. The reversal of deafness in one of our patients and stabilization in the others made us wonder whether an inherited enzymopathy had been reversed, which then mitigated the deafness.
Between 1950 and 1970, 44 patients (2.5 per cent) with renal cell carcinoma and a solitary metastatic lesion were treated at our clinic. Generally, treatment was aggressive, involving nephrectomy and excision of the metastatic lesion when possible. Patients presenting with the primary and metastatic lesion at the same time did not do as well as patients who presented with metastasis after nephrectomy. An operation for the metastatic lesion seemed to offer the best results in patients who presented with the solitary metastatic lesion after nephrectomy. The prognosis was uniformly poor in patients presenting with the primary and secondary lesion together, regardless of the mode of therapy. However, an operation seemed to be better marginally and did produce an occasional long-term survival.
The extended experience on the efficacy of pretreating the cadaveric renal allograft donor by means of large doses of cyclophosphamide and methylprednisolone (group A, 36 kidneys) was compared with the experience regarding untreated renal allografts (group B, 32 kidneys). Kidneys in both groups were perfused by pulsatile means using cryoprecipitated plasma. There was a significant difference in allograft survival (72% in group A versus 36% in group B at 3 years by actuarial means). Also, large doses of cyclophosphamide and methylprednisolone as pretreatment did not cause any detrimental effect to the allograft kidney when used in combination with cryoprecipitated plasma and pulsatile perfusion.
Forty patients (including 37 juvenile diabetic patients) with insulin-dependent diabetes mellitus and end-stage renal failure received 42 renal allografts during the interval from June 1970 to December 1975. Of the 30 patients who are alive (between six and 72 months after transplantation; average, 29 months), 19 have been fully rehabilitated. Gangrene of peripheral extremities occurred in 30% of the survivors. The use of "pretreated" cadaveric kidneys in the diabetic patient may become an attractive alternative to grafts from living related donors. Renal transplantation with living related and pretreated cadaveric donor kidneys is the treatment of choice and is superior to dialysis in the insulin-dependent diabetic patient with end-stage renal disease.
Levels of serum lactic dehydrogenase (LDH) were determined in renal transplant recipients to assess their value as consistent predictors of acute allograft rejection. Although serum LDH levels of more than 250 U/l were in most cases associated with irreversible graft rejection, they were unreliable as a predictor or as an early indication of allograft rejection. Their chief value appears to be as an aid in determining when to discontinue high dose immunosuppression in an attempt to save an allograft that is most probably doomed to ultimate failure.
The intravenous administration of high doses of methylprednisolone and cyclophosphamide during pretreatment of the heart-beating canine and human cadaveric allograft donor has caused no observable adverse effect on renal allografts. This is in contrast to that noted when high doses of these drugs are added to the preservation perfusate in which they are not metabolized and may possibly cause renal damage.
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Ureteral obstruction occurring five years or more after renal transplantation is uncommon and may mimic allograft rejection. In 2 patients who had received cadaveric renal allograft, ureteral obstruction was detected six and one-half and five and one-half years after transplantation. In both patients, surgery was needed to restore normal renal function and to prevent further renal damage. Excretory urography is important in the follow-up of patients who have undergone renal transplantation, and conditions such as ureteral obstruction should be ruled out before antirejection treatment is started.
Urinary diversion may be used in patients without a bladder or with irreversible, lower urinary tract abnormalities who might not otherwise be suitable candidates for renal transplantation. Three cases have been described to illustrate three different methods of supravesical urinary diversion that have been employed in association with renal transplantation.
Excellent cadaver allograft survival has been achieved with kidneys from cadaver donors pretreated with high intravenously given dosages of cyclophosphamide and intravenous injections of methylprednisolone. To test the efficacy of this method of pretreating the donor, allograft survival in 21 patients, group A, receiving kidneys from cadaver donors pretreated with 4 grams of cyclophosphamide and 4 to 6 grams of methylprednisolone given intravenously was compared with two other groups of cadaver allograft recipients, 39 patients, 23 group B patients receiving untreated kidneys harvested at the Mayo Clinic and 16 group C patients receiving untreated kidneys harvested elsewhere. Two year actuarial allograft survivors were 16 of 21 in group A, 13 of 23 in group B and seven of 16 in group C. We believe that cadaver donor pretreatment improves allograft survival significantly.
The additional use of routine tomography during excretory urography in our experience has led to a significant improvement in urographic diagnosis. Tomography has provided more diagnostic studies, it also has demonstrated tumors which would have remained undetected with the use of conventional urography alone. This applies particularly to small hypernephromas of stage A, which should be considered as curable.
En bloc bilateral cadaveric nephrectomy for transplantation has some advantages over excision of each kidney separately. There is also an advantage of single cannula perfusion through the aorta for two kidneys, especially when multiple renal arteries are present. The anatomic vascular variants are important, as are the incision and the approach to the suprarenal aorta and the lumbar venous drainage of the kidney.
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A technique of internal marsupialization of lymphoceles after renal transplantation in selected cases is described. This technique allows complete marsupialization of retrorenal lymphoceles not amenable to external marsupialization. It also can be carried out during concomitant intraperitoneal surgical procedures.
Plasma insulin and glucose levels were measured before and for twenty-four hours after operation in 13 patients who had undergone renal transplantation, 4 who had undergone bilateral nephrectomy, and 5 who had undergone donor nephrectomy. Postoperative hyperglycemia was noted in all patients, but the hyperglycemia was much greater after renal transplantation. Peripheral insulin antagonism rather than decreased insulin secretion appeared to account for the hyperglycemia. The peripheral insulin antagonism was largely due to surgical stress, but intravenous immunosuppressive medications contributed to the exaggerated hyperglycemia, hyperinsulinemia, and insulin antagonism observed in the transplant patient.
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