Biomedical subjects
Publications and source records attributed to L H Banowsky.
Calciphylaxis occurs in renal transplant patients more frequently than in chronic hemodialysis patients. It can occur in a patient with normal renal function who is also normocalcemic. Early parathyroidectomy can lead to healing of the skin lesions and prevent death of sepsis.
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Infections of the head and neck were identified in 12 (9%) of 128 consecutive patients undergoing renal transplantation. The infections included sinusitis, otitis media, dental abscess, Ludwig's angina, parotitis, and nasal abscess. A significant correlation was found between the development of infection and juvenile-onset diabetes but not with previous splenectomy. None of the infections occurred during treatment of rejection episodes with corticosteroids. The clinical presentations and microbiologic agents causing the infections were similar to those found in nonimmunosuppressed patients.
Recipients of cadaveric kidney transplants before 1975 had a 1-year mortality rate (30 per cent) approximately 3 times higher than patients on chronic hemodialysis (10 per cent). Patient survival was no better in large than in small transplant centers. Since 1975 several large and experienced transplant centers (more than 500 transplants) have reported improved patient survival rates (90 per cent). We herein document that a small transplant center (less than 200 transplants) can achieve patient survival rates that are equivalent to larger transplant centers.
Pretransplant bilateral nephrectomy by the posterior approach has been associated with minimal morbidity and mortality. Unfortunately the posterior approach is not applicable to all patients, e.g., patients with polycystic renal disease or patients who need simultaneously another intraperitoneal adjuvant operation such as splenectomy or vagotomy and pyloroplasty. This article presents 34 patients who had a transperitoneal bilateral nephrectomy and 29 other concurrent adjuvant operations. Morbidity and mortality are comparable to that reported for simple bilateral nephrectomy performed posteriorly. The reduction in morbidity and mortality was believed to be due to a careful application of the basic principles of surgical care and an appreciation of the special problems posed by patients on chronic hemodialysis. Perioperative care will be discussed in detail.
HLA-A and -B antigens were determined for 300 unrelated Mexican-Americans and 300 unrelated Caucasians from San Antonio by the microlymphocytotoxicity technique, using lymphocytes isolated from freshly drawn peripheral blood. Haplotype frequencies for the Mexican American population were obtained directly, based on family studies, as well as estimated from phenotype data. The results revealed clear differences in the distribution of HLA antigens between Mexican American and Caucasian populations. The predominant HLA specificities in Mexican Americans were A2 and Bw35, while the most frequently observed haplotypes were A2-Bw35, A2-B12 and A2Bw40. Despite the distinct differences in HLA antigen distribution between Mexican American and Caucasian populations, genetic distance values, calculated from the HLA frequencies, were surprisingly low.
With the entity of normocalcemic primary hyperparathyroidism increasingly prevalent in the literature the treatment of parathyroidectomy has been advocated. A total of 21 patients with recurrent calcium-containing calculi and normocalcemia underwent parathyroidectomy. Of the 21 patients 1 had an adenoma, 9 had hyperplasia and 11 had normal glands. Of the 19 patients followed stones ceased forming in 32 per cent, while in 42 per cent calculi continued to form. Of 5 patients with multiple unassessable calculi 1 ceased passing stones. We conclude that the entity of normocalcemic hyperparathyroidism is rare and repeated serum calcium determinations to identify true hypercalcemic hyperparathyroidism are necessary.
Predicting the outcome of human renal allografts based on studies of one hour biopsy specimens is still controversial. We have tried to correlate histologic, ultrastructural, and immunofluorescence findings in 96 one hour biopsy specimens with histocompatibility matching, the presence of preformed antibodies, allograft ischemia and preservation times, the donor's age, the original renal disease, and allograft source, function, and survival. Ultrastructurally, 22 allografts had fibrin deposits in glomerular loops. There was a significant correlation between this finding and poor allograft function (p < 0.01), cold ischemia time (p < 0.02), and cadaveric allograft source (p < 0.01). Sixteen allografts showed epithelial cell detachment from tubular basement membranes. This finding correlated with cadaveric allograft source (p < 0.01). Many other morphologic changes were evaluated by both light and electron microscopy, but they did not bear any significant relationship to any of the aforementioned clinical parameters. Of 30 biopsy specimens studied by direct immunofluorescence, 11 showed positive findings (immunoglobulins or C3) in either glomeruli, vessels, or both. There was no significant correlation between these findings and the clinical parameters.
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A controlled canine experimental study has been performed to test the application of a biodegradeable graft to vesical augmentation. The graft, after providing initial bladder enlargement, is progressively reabsorbed while serving as a foundation for the regeneration and healing of the layers of the bladder remnant. Follow-up studies at 1 year revealed no urinary infection, calculi, extravasation of urine, or rejection of the material. Normal bladder capacities were maintained throughout the study and the reconstructed bladders functioned normally. The biodegradable graft was equally successful when applied either to a histologically normal bladder remnant, or to a pathological bladder of intramural fibrosis. These results suggest that this material may be well suited to clinical bladder substitution in humans.
From January 1, 1971, to January 1, 1976, 173 renal allografts were transplanted into 146 patients. Intravenous methylprednisolone (IVMP) was given to all mismatched recipients in a dose of 1 Gm. on the day of transplant and in varying amounts during acute allograft rejection. In 7 patients, 4.8 per cent of 146 patients and 4 per cent of 173 allografts, with a minimum follow-up of fifteen months avascular necrosis of one or more joints developed with an average of 9.4 months after transplantation and a range of five to eighteen months. The total dose of IVMP given to the patients with aseptic necrosis varied between 3 and 18 Gm. from the time of transplantation until the onset of skeletal symptoms. This incidence was nearly identical to the 5 per cent of 242 patients and 4.3 per cent of 276 renal allografts from the same center performed between January 1, 1963, and January 1, 1971, when intravenous steroid pulse therapy was not utilized. Since January, 1971, total joint replacement of the hip or knee were performed in 4 of the 7 affected patients six to sixteen months after the onset of symptoms. Renal function remained stable after surgery in all 4 patients. Virtually normal range of motion was present within three months after surgery. Although the controversy of steroid therapy in the pathogenesis of avascular necrosis still exists, judicious use of high-dose IVMP therapy does not appear to increase its incidence. Early surgery is recommended when the radiologic evidence confirms the clinical findings of avascular necrosis in order to ameliorate pain, correct restriction of movement, and promote full rehabilitation.
From January, 1963, to January, 1977, 4 cases of acute allograft rupture occurred in 474 renal transplants performed at the Cleveland Clinic, an incidence of 0.8 per cent. Rupture developed between the fifth and sixteenth day after transplantation during a period when the patients required dialysis because of poor allograft function. All patients had surgical exploration and successful repair of the laceration. Biopsies in each case at the site of laceration revealed findings consistent with acute allograft rejection. The rejections were mild in 2 cases, moderate in one, and severe in another. Two kidneys failed to sustain function, and the patients were returned to chronic hemodialysis two to five months later. None required a nephrectomy. The other two kidneys are functioning well, with serum creatinine values of 1.3 and 1.5 mg./100 ml. one year after allograft rupture. Since rupture of a renal allograft does not appear to increase the intensity of rejection nor does it represent a severe type of rejection, transplant nephrectomy can be avoided unless hemorrhage is uncontrollable from the site of laceration.
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A controlled experimental study has been performed using a biodegradable graft of natural tissue to achieve vesical augmentation. The graft is progressively reabsorbed while normal capacity is maintained by concomitant regeneration of the layers of the bladder remnant. No significant complications were encountered, and the graft was equally successful when applied either to a histologically normal bladder or to a pathologic bladder of intramural fibrosis. This material is potentially ideal for clinical bladder substitution in humans.
Autotransplantation, with or without an extracorporeal renal operation, has been done 39 times in 37 patients. Indications for the procedure included several ureteral injury in 4 patients, failed supravesical diversion in 2, renal carcinoma in a solitary kidney in 1, renovascular hypertension in 1 and donor arterial reconstruction before renal transplantation in 29. Success was obtained in all but 2 procedures, both of which involved previously operated kidneys with severe inflammation and adhesions involving the renal pelvis and pedicle. Based on our experience and a review of currently available literature we believe that renal autotransplantation and extracorporeal reconstruction can provide the best solution for patients with severe renovascular and ureteral disease not correctable by conventional operative techniques. The technique can be of particular value in removing centrally located tumors in solitary kidneys and in preparing donor kidneys with abnormal arteries for renal transplantation. The role of autotransplantation in the management of advanced renal trauma and calculus disease is less clear. A long-term comparison of patients treated by extracorporeal nephrolithotomy versus conventional lithotomy techniques will be necessary before a conclusion is reached in these disease categories.
During a 20-year period 17 patients underwent partial nephrectomy as primary curative therapy for renal adenocarcinoma. In 15 patients (88 per cent) partial nephrectomy was performed satisfactorily in situ with free margins of resection. Eleven patients are alive (65 per cent) and only 3 (17 per cent) died of recurrent malignant disease. There was no operative mortality and postoperative complications were minimal. A review of the literature reveals that partial nephrectomy is an effective form of therapy for patients with bilateral renal carcinoma or carcinoma occurring in a solitary kidney.