Biomedical subjects
Publications and source records attributed to J Bellamy.
The authors report two cases of aneurysm in renal transplantation: one after removal of the transplant and the other with the transplant in place. In both cases, repair was preceded by excision of the aneurysm and consisted of interposition of an inverted autologous vein graft.
An increased incidence of Kaposi's sarcoma is well known in renal transplant recipients in whom it may represent up to 3 p. 100 of all de novo tumours. This sarcoma has a close relationship with the potential oncogenicity of the cytomegalovirus (CMV) and with chronic immunological deficiency. Anti-CMV immunity is based on the integrity of cytotoxic cellular functions such as those of cytotoxic T lymphocytes (CTL), "natural killers" cells, and K cells which function in the antibody-dependent cell cytotoxicity (ADCC) system. Two cases of Kaposi's sarcoma were observed out of a total of 700 renal transplant recipients; they underwent the following investigations: lymphocyte sub-group counts by murine monoclonal antibodies, lymphocyte proliferation to lectins and allogenic cells, NK activity and generation of specific auxiliary and cytotoxic anti-CMV cells. Both cases of Kaposi's sarcoma were seropositive for CMV and seronegative for LAV. In one case, an abnormal number of peripheral OKT9 + lymphocytes (normally a thymocytic marker) was observed with small numbers of OKT4/OKT8, a reduced proliferative response to mitogens and allogenic cells. All these in vitro changes persisted despite reduction of immunosuppressive therapy and clinical improvement. A clinical and biological cure was only obtained after withdrawal of immunosuppressive therapy and return to haemodialysis. In the second case of Kaposi's sarcoma, the initial biochemical changes were minimal and a clinical cure was obtained by decreasing the immunosuppressive therapy. These two cases illustrate the complex dysregulation of the immune system in Kaposi's sarcoma.
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Fifty-six renal artery stenoses involving transplanted kidneys among a series of 819 renal transplants performed from 1978 to 1986 were treated. Forty-two patients underwent surgery. Surgery was the initial treatment in 38 cases and followed failed or complicated dilatation in four cases. Surgical treatment ensured successful control of hypertension in 85% of cases with a mean time lag of 26 months. Recurrence rate was 12%. Two patients died in the perioperative period. Percutaneous dilatation was performed in 18 renal artery stenoses and ensured control of hypertension in 61% of cases with a mean time lag of 19.6 months and a 33% recurrence rate.
A prospective study was conducted on 57 high-risk patients having received cadaver renal transplants between January 1983 and May 1984, and submitted to the triple combination: cyclosporine, azathioprine, and steroids. 23 patients of Group I including 12 pre-sensitized and poorly matched recipients were treated from the Day 1 post-transplant. 34 patients of Group II received the triple combination following a steroid-ALG resistant rejection. Actuarial graft survival in the whole group was 74%, 64%, and 64% at 1, 2, and 3 years respectively. Patient survival was 100% in the Group I, vs 85% at 1 year, and 82% at 2 years in the group II (p less than 0.02). The incidence of infectious complications and infectious deaths was significantly higher in patients of Group II. Our results suggest the effectiveness of a triple low-doses combination in high-risk renal transplantation, but the delayed use of this combination following a treatment with high-doses of steroids and ALG fails to reverse the rejection, with an obvious overimmunosuppression risk.
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The authors presented their observations of four patients who were operated on for a supra-infection of emphysematous bullae by Mycobacterium xenopi. In two cases the patients were operated on without a diagnosis and excision of the right upper lobe assured their cure. The other patient underwent a decortication and ultimately relapsed. The fourth had a bilateral apical infection and underwent bilateral excision. A survey of the literature leads one to think that pulmonary infections with a Mycobacterium xenopi occur in emphysematous bullae more often than is generally thought. The unreliability of the results of antituberculous drugs, the complications of treatment and the risks of recurrence after treatment are well known. Controlled surgical excision of the lesions, which is most often followed by a definitive cure, always merits consideration as part of the therapeutic arsenal.
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Four hundred and thirty renal transplantations have been performed over a 5-year period during which there was a switch of surgical technique towards uretero-vesical anastomosis. In this paper, the urological complications observed are studied according to the site of transplantation, the position of the kidney, the type of anastomosis and the length of the ureter. Kidneys that were transplanted in iliac position gave rise to more complications than those transplanted in pelvic position, and reversing the kidney increased the number of urological complications. The complication rate was 6.7% with the uretero-vesical anastomosis and 12% with the uretero-ureteral anastomosis. The best results were obtained when the kidney was transplanted into the iliac fossa in pelvic position with its upper pole upward and its ureter anastomosed with the bladder: in 274 transplantations performed with this technique the complication rate was 4.7%. This study of different types of transplantation shows that the main factor is the ureteral length utilized: the longer that segment of the ureter, the more numerous the urological complications.
We report the case of a 30-year old male patient who presented with chronic right lung purulence of 10 years' duration and of undetermined origin. At pneumonectomy a fistula joining the oesophagus to the cavities in the right lower lobe was discovered. Non tumoral oesophago-bronchial or oesophago-tracheal fistulae are rare, but oesophago-pulmonary fistulae are truly exceptional, since only 3 cases were found in the literature. The possible causes of this pathology in our patient are discussed.
Cyclosporin A significantly improves patient and graft survival as compared with the conventional corticosteroid-azathioprine treatment. However, the results are the same, or even worse, when the cyclosporin A-corticosteroid regimen is compared with the corticosteroid-azathioprine-antilymphocyte globulin regimen. The authors have investigated a prednisone-azathioprine-low dose cyclosporin A combination in 46 high risk patients from a series of 117 renal transplantations performed in 1983. The actuarial patient and graft survival rates were as good as, but not better than, those obtained in 1982 in 106 patients treated with the conventional regimen which includes antilymphocyte globulin; they were 96.5% vs 98% and 85.5% vs 84% respectively at 6 months; 96.5% vs 98% and 83.5% vs 84% respectively at 12 months. The low dosage utilized (8 mg/kg instead of the usual 14-17 mg/kg) avoided virtually all the extrarenal side-effects of cyclosporin A, but not its nephrotoxicity. The theoretical risk of excessive immunosuppression was not confirmed by our study. Since cyclosporin A is very expensive, other therapeutic methods for optimal usage of that drug should be investigated.
In order to evaluate precisely the place of continuous ambulatory peritoneal dialysis in the treatment of chronic renal failure, it is important to find out whether this method may produce complications, mostly infectious, after renal transplantation. From April, 1979 to December, 1983, 419 renal transplantations were performed in our centre; 17 of these patients had previously been treated with peritoneal dialysis over a mean 13.5 months period, with 3.2 peritonitis/patient. The peritoneal catheter was left in situ for 4 to 16 weeks post-graft, so that the patients could easily be dialysed if needed; it was removed during transplantation in the only 3 cases of recent peritonitis. The only complications noted after transplantation were an episode of spontaneously reversible ascites and a peritoneal breach following reintervention on the renal region. This homogeneous series confirms that continuous ambulatory peritoneal dialysis does not constitute a contra-indication, let alone an obstacle, to subsequent renal transplantation. Indeed, it may be regarded as the first-choice method for patients in whom early grafting is envisaged on account of their immune status.
The authors report a series of 430 renal transplantations performed over five years. During this period, the surgical technique was modified to ureterovesical anastomosis. The urological complications--fistulae and stenosis--are discussed as a function of the site of the implantation, the position of the kidney, the type of anastomosis and the length of the ureter. The results show that transplantation in the iliac position gives rise to more complications than transplantation in the pelvic position. They also show that inversion of the superior pole of the kidney leads to a greater number of urological complications. In the series reported, ureterovesical anastomosis gave 6.7% of complications, against 12% for uretero-ureteral anastomosis, which also gave rise to a significantly larger number of fistulae. More detailed study of the series reveals a complication rate of 4.7% for ureterovesical anastomosis (out of 224 patients) against 4% for uretero-ureteral anastomosis, when the ureter was short (in both series). The dominant factor is therefore the length of the ureter; the longer it is, the greater the number of urological complications.
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The authors describe five cases of renal allograft rupture as a result of acute rejection. In one case of perineal hematoma, no operation was performed. The evolution of the hematoma led to a periureteral sclerosis, which was successfully operated. The authors advocate deferring the surgical management of allograft ruptures. Once the diagnosis has been established with the aid of physical examination, electrography and computerized scanography, the extra time can be devoted to following the evolution of the rejection. If the rejection is irreversible, a nephrectomy has to be performed, but if it is reversible, they favour conservative treatment followed by operative intervention around the tenth day.