Biomedical subjects

S B Streem

Publications and source records attributed to S B Streem.

At least 91 records · Page 5Linked to original sources

PubMed1992

Long-term followup after nephron sparing surgery for renal cell carcinoma in von Hippel-Lindau disease.

We reviewed the long-term outcome of nephron sparing surgery in 9 patients with localized bilateral renal cell carcinoma and von Hippel-Lindau disease. One patient died of metastatic renal cell carcinoma 43 months postoperatively. One patient has not had recurrent tumor and was alive at 74 months postoperatively. The remaining 7 patients (mean followup 88 months) had local recurrence of tumor in the operated kidney and a secondary renal operation was done in 6 of them. Overall, 6 patients are free of tumor but only 3 of them retain functioning native renal parenchyma. We conclude that the results of nephron sparing surgery in patients with renal cell carcinoma and von Hippel-Lindau disease are less satisfactory than in patients with sporadic renal cell carcinoma.

Adult↗

PubMed1991

Role of percutaneous nephrostomy in patients with upper urinary tract transitional cell carcinoma.

Percutaneous nephrostomy has become a well-established procedure for a wide variety of urologic disorders. However, its role in the management of patients with upper urinary tract transitional cell carcinoma has not been defined. We utilized percutaneous nephrostomy in 23 renal units for the evaluation or treatment of 21 patients in whom standard techniques were inconclusive or inadequate. The percutaneous nephrostomy provided adequate relief of obstruction in the face of significant azotemia or infection. Diagnostic abilities were improved through the use of antegrade pyelography, selective cytologic examination, and, at times, by providing direct access for endoscopic visualization and biopsy. In select cases, the percutaneous access provided a route for definitive or adjunctive treatment of the lesion. Complications were few and seeding of the tract or local tumor spread has not occurred at follow-up ranging from one to one hundred twenty-one (mean 27.8) months.

Adult↗

PubMed1991

Pericarditis following renal transplantation.

We analyzed data on renal allograft recipients over a 27-year period in order to investigate the frequency, etiology, and outcome of pericarditis developing during the first two months following renal transplantation. Of the 1497 patients receiving renal transplants between 1963 and 1990, 34 patients developed 36 episodes of pericarditis and/or pericardial effusions, for an overall incidence of 2.4%. Pericarditis was attributed to uremia in 14 episodes, cytomegalovirus infection in three, both uremia and CMV infection in four, nonspecific bacterial infection in three, and tuberculosis and minoxidil therapy in one episode each. No etiologic diagnosis could be established in 10 episodes. No statistically significant differences were found between pericarditis and case-matched control patients considering demographic features, the number of immediately functioning grafts, the duration of posttransplant acute renal failure, the number of supportive dialysis days, pre- and postoperative CMV status of the patients, and pretransplant BUN and serum creatinine levels. There were more uremic-related complications (pulmonary edema, gastrointestinal bleeding, central nervous system symptoms) in the pericarditis group. Five allografts in the pericarditis group never functioned, versus only one in the control group. Three patients with pericarditis developed pericardial tamponade. Early diagnosis, close follow-up, and in the case of cardiac tamponade early invasive treatment, should improve the prognosis of this potentially life-threatening complication.

Adolescent↗

PubMed1991

Comparison of OKT3 with ALG for prophylaxis for patients with acute renal failure after cadaveric renal transplantation.

A randomized, prospective comparison of OKT3 vs. ALG (University of Minnesota) was performed in patients who had acute renal failure after a cadaver renal transplantation. Criteria for admission to the study were oliguria or increasing serum creatinine in the first 12 hr after renal transplantation. ALG or OKT3 was administered after randomization beginning 12-36 hours posttransplantation. There were no significant differences in age, sex, original disease, ischemia time, or HLA matching between groups. Graft survivals at 1 and 6 months were 84% and 84%, respectively for the ALG group. One- and 6-month graft survival for the OKT3 group was 88% and 84%, respectively. These differences were not statistically significant. The number of rejection episodes and the number of patients with rejection episodes were greater, and the time to first rejection was shorter in the OKT3 group compared with the ALG group, although none of these differences reached statistical significance. There were significantly less side effects in the ALG group compared with the OKT3 group (P less than .05). The greatest reductions in side effects were in fever and hypotension. Patients were monitored with flow cytometry analysis measuring the number of CD2 (T11) and CD3 (T3) cells to adjust the dose of both OKT3 and ALG. Starting doses were 10 mg/kg/day of ALG and 5 mg/day of OKT3. There were no significant differences in the incidence of infections (viral or bacterial) between the two groups. There were no rejection episodes during the prophylactic therapy with either ALG or OKT3. In summary, both ALG and OKT3 provided effective prophylaxis for patients with acute renal failure after renal transplantation. OKT3 was associated with a statistically significant increase in incidence of symptomatic side effects.

Acute Kidney Injury↗

PubMed1991

The development of proteinuria and focal-segmental glomerulosclerosis in recipients of pediatric donor kidneys.

Several reports in animals, and sporadic case reports in humans, have suggested that kidneys with decreased nephron mass may be more susceptible to the development of focal-segmental glomerosclerosis. This prompted a reexamination of our previously reported group of pediatric donor-adult recipient renal transplant combinations. Data were analyzed from 31 adult recipients who had received renal transplants from cadaver pediatric donors (less than 6 years) with graft function for greater than 6 months and no evidence of chronic rejection. These were compared with a control group transplanted during the same period with adult donor kidneys. Immunosuppression consisted of azathioprine/prednisone or quadruple therapy in 16 and 15 patients respectively. End-stage renal disease (ESRD) was secondary to chronic glomerulonephritis (n = 9), diabetes mellitus (n = 6), polycystic kidney disease (n = 5), and miscellaneous causes (n = 11). Twenty patients had radiographic documentation of renal hypertrophy posttransplant. All patients had serial 24-hr urinalysis for protein and creatinine after transplantation during periods of stable renal function. Ten patients had renal biopsies performed at a mean time from transplant to biopsy of 10.4 +/- 1.6 months. Seven recipients had biopsies that revealed glomerulosclerosis at 13 +/- 6 months posttransplant. Protein excretion and serum creatinine in these patients were significantly higher than in control patients (1.6 +/- 0.37 vs. 0.49 +/- 0.15 g/24 hr and 1.96 +/- 0.11 vs. 1.64 +/- 0.09 mg%; P less than 0.03 and P less than 0.01, respectively). Only 3 of 25 control adult donor recipients developed proteinuria greater than 0.8 g/24 hr within 2 years of transplantation vs. 15/31 pediatric donor recipients. No correlations with the etiology of ESRD, age (greater than or less than 40 years), weight, sex, diabetes, hypertension, or the number of acute rejection episodes could be found. Our data suggest that adult recipients of pediatric donor renal transplants may be at greater risk for the development of glomerulosclerosis than those recipients receiving adult donor kidneys.

Adult↗

PubMed1991

Resection of inferior vena cava tumor thrombi from renal cell carcinoma.

Renal cell carcinoma is an unusual cancer with the propensity to invade not only the renal vein but to propagate into the inferior vena cava (IVC) as a tumor thrombus. Experience has recently confirmed that MRI will be valuable in evaluating the extent of the tumor thrombus. The surgical techniques used to remove the thrombus are dependent on the extent of the cancer. For lesions involving the infrahepatic IVC, only proximal and distal control of the IVC are necessary. For a thrombus involving the intrahepatic IVC, isolation of the suprahepatic IVC, hepatic circulation, and infrahepatic IVC or cardiopulmonary bypass can be used. For the large thrombus in the supradiaphragmatic IVC or atrium, cardiopulmonary bypass either with or without deep hypothermic circulatory arrest is appropriate. In a review of 48 cases with renal cell carcinoma with IVC tumor thrombi, the tumor thrombus was removed intact in 58 per cent and in multiple fragments ("piece-meal") in 42 per cent of the patients. Cardiac bypass has been used in 26 cases with 22 undergoing deep hypothermic circulatory arrest. The postoperative mortality of 48 cases between 1965 and 1987 was 4 per cent. Removal of the most complicated and extensive renal cell carcinoma tumor thrombi is now technically feasible. In patients with large tumor thrombi, however, the ultimate outlook remains poor in the absence of effective systemic adjuvant therapy.

Carcinoma, Renal Cell↗

PubMed1991

Renal cell carcinoma with inferior vena cava tumor thrombi.

Renal cell carcinoma is a unique neoplasm because of its common propensity to propagate into the renal vein and inferior vena cava (IVC) as tumor thrombus. Historically, the surgical difficulties encountered in removal of these cancers limited the ability of a single institution to obtain experience with large numbers of instances. Between January 1956 and July 1987, 68 patients with renal cell carcinoma extending into the IVC or right atrium underwent radical nephrectomy with vena cava thrombus extraction at the Cleveland Clinic. Twenty-five patients had partial resection of the IVC with reconstruction. Fifteen patients had partial resection and reconstruction of the IVC; however, because of narrowing of the infrarenal IVC, persisting bland thrombus in the proximal IVC or iliac veins or concern regarding postoperative pulmonary emboli, the infrarenal IVC was either ligated or clipped. Seven patients underwent cavectomy with division of the IVC. A right atriotomy was performed upon 14 patients and cardiopulmonary bypass was used in 20 patients, with 17 also having deep hypothermic circulatory arrest. The tumor thrombus was removed intact in 64 per cent of the patients and in multiple small fragments ("piecemeal") in 36 per cent of the patients. The mortality rate was 7 per cent. Survival was examined relative to extent of vena caval thrombus. Patients with extension into the atrium had a significantly worse prognosis than those with other levels of vena caval involvement. Other factors, such as lymph node status, perinephric fat involvement, resection of IVC and intact or "piecemeal" extraction, did not influence the survival rate. Patients with pre-existing metastases preoperatively had an extremely poor survival rate. The techniques now available for surgical resection of all levels of tumor thrombus of the IVC make resection feasible in most patients. In our opinion, the addition of deep hypothermic circulatory arrest has been a significant advance.

Carcinoma, Renal Cell↗

PubMed1990

Outcome of renal transplantation in patients with a functioning graft for 20 years or more.

In the present study long-term morbidity, quality of life and over-all rehabilitation were assessed in 14 patients with a functioning renal allograft for 20 years or longer. Followup ranged from 20 to 27 years (mean 22.5 years). All patients enjoyed excellent and stable renal function, and the mean serum creatinine level at 20 years was 1.3 mg. per dl. Complications related to long-term immunosuppressive therapy comprised infection in 8 patients (57%), malignancy in 7 (50%), cardiovascular disease in 6 (43%), cataracts in 3 (21%) and avascular necrosis of the hip in 2 (14%). Over-all quality of life was excellent in 13 patients who were able to return to work, participate in pre-illness levels of activity and enjoy sexual activity. While successful renal transplantation allows patients with end stage renal failure to resume relatively normal lives, these patients remain prone to complications resulting from long-term immunosuppressive therapy.

Aged↗

PubMed1990

Magnetic resonance imaging for assessment of vena caval tumor thrombi: a comparative study with venacavography and computerized tomography scanning.

We assessed the accuracy of magnetic resonance imaging in demonstrating the presence and extent of vena caval tumor thrombi. The study group included 20 patients with vena caval thrombi from renal cell carcinoma (18), renal pelvic transitional cell carcinoma (1) and adrenal pheochromocytoma (1). Preoperative diagnostic studies included magnetic resonance imaging in all patients, inferior venacavography in 16 and computerized tomography scanning in 15. All patients underwent an operation in which the presence and extent of the vena caval thrombus were confirmed. Magnetic resonance imaging accurately delineated the presence and extent of the thrombus in all 20 patients (100%). Venacavography was accurate in 15 patients (94%) but 8 (50%) required a retrograde and antegrade study. Computerized tomography scanning demonstrated the presence of a tumor thrombus in all 15 patients but accurately delineated the cephalad extent of the thrombus in only 5 (33%). In patients with vena caval tumor thrombi magnetic resonance imaging can provide accurate information regarding the extent of vena caval involvement while avoiding the need for an invasive contrast imaging study.

Adrenal Gland Neoplasms↗

PubMed1990

Extracorporeal shock wave lithotripsy in patients with bleeding diatheses.

Five patients with known bleeding diatheses were treated with extracorporeal shock wave lithotripsy. Specific therapy was administered before extracorporeal shock wave lithotripsy to reverse the bleeding disorder. After treatment each patient was monitored with serial hemoglobin determinations and renal ultrasonography. The course during and after lithotripsy was uneventful in all patients. We conclude that extracorporeal shock wave lithotripsy is a viable option for patients with significant bleeding diatheses provided that specific therapy to reverse the coagulopathic condition is available and used before treatment.

Female↗

PubMed1990

Nephron-sparing surgery for renal cell carcinoma with venous involvement.

A nephron-sparing operation recently has been shown to provide extended survival free of disease in selected patients with localized renal cell carcinoma, particularly for tumors of lower stage. To define better the role of conservative surgical treatment in more locally advanced renal cell carcinoma we reviewed 9 patients with venous tumor involvement in solitary functioning kidneys who underwent a nephron-sparing operation. Complete tumor resection with adequate preservation of renal function was accomplished in all cases. Of the 9 patients 5 had no evidence of disease 7 to 93 months (mean 33.2 months) postoperatively. The remaining 4 patients died of metastatic renal cell carcinoma 17 to 47 months (mean 35.5 months) postoperatively, 2 of whom had concomitant local recurrences in the renal remnant. Based on previously reported results of total nephrectomy for renal cell carcinoma with venous involvement and the morbidity associated with renal replacement therapy, we believe that a nephron-sparing operation is a viable option in the management of these patients.

Carcinoma, Renal Cell↗

PubMed1990

A simple and accurate grading system for orthoiodohippurate renal scans in the assessment of post-transplant renal function.

Orthoiodohippurate renal scanning has proved to be a reliable, noninvasive method for the evaluation and followup of renal allograft function. However, a standardized system for grading renal function with this test is not available. We propose a simple grading system to distinguish the different functional phases of hippurate scanning in renal transplant recipients. This grading system was studied in 138 patients who were evaluated 1 week after renal transplantation. There was a significant correlation between the isotope renographic functional grade and clinical correlates of allograft function such as the serum creatinine level (p = 0.0001), blood urea nitrogen level (p = 0.0001), urine output (p = 0.005) and need for hemodialysis (p = 0.007). We recommend this grading system as a simple and accurate method to interpret orthoiodohippurate renal scans in the evaluation and followup of renal allograft recipients.

Adult↗

PubMed1990

Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi.

From June 1984 to September 1989, 43 patients with large vena caval tumor thrombi from retroperitoneal malignancies underwent surgical treatment with cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). The primary malignancies were renal cell carcinoma (RCC) (n = 39), renal pelvic transitional cell carcinoma (n = 1), adrenal pheochromocytoma (n = 1), and renal (n = 1) or retroperitoneal (n = 1) sarcoma. The level of the caval thrombus was either suprahepatic (n = 27), intrahepatic (n = 14), or subhepatic (n = 2). In all cases the primary tumor and caval thrombus were completely removed. Concomitant procedures included coronary artery bypass grafting (n = 5), pulmonary resection (n = 2), and hepatic lobectomy (n = 1). The time of circulatory arrest ranged from 10 to 44 minutes (mean, 23.5 minutes). There were two operative deaths (4.7%), neither of them due to to the use of DHCA. Major postoperative complications occurred in 13 patients (30.2%). There were no ischemic or neurologic complications and no cases of perioperative tumor embolization. The median postoperative hospital stay was 9 days. Twenty-two patients (51%) are alive and enjoying a good quality of life. The 3-year patient survival rates in patients with localized (n = 24) versus metastatic (n = 15) RCC are 63.9% and 10.9%, respectively (p = 0.02). We conclude that CPB with DHCA facilities excision of retroperitoneal malignancies with large caval thrombi and provides the potential for cure with low morbidity and mortality rates.

Adult↗

PubMed1990

Intravenous immunoglobulin infusions for the prophylaxis of secondary cytomegalovirus infection.

Previous studies have shown a benefit of intravenous immunoglobulin infusions for the prophylaxis of primary CMV infections in renal transplant recipients. This study was undertaken in order to see if high-risk renal transplant patients at risk for secondary CMV infection would benefit from prophylactic intravenous immunoglobulin infusions. A randomized prospective study of renal transplant recipients who were considered at high risk for secondary CMV infection was performed. Thirty-four patients were studied, 16 receiving the intravenous immunoglobulin infusions and 18 being untreated controls. Unselected lots of Sandoglobulin (Sandoz) were used for the treatment group (500 mg/kg x 3 doses, followed by 250 mg/kg x 2 doses at 2-week intervals). The number of days febrile and days hospitalized secondary to CMV illness, and the number of complications secondary to CMV illness, were significantly reduced in the patients who were prophylactically treated with intravenous immunoglobulin infusions. None of the patients died from CMV infection in either group. There were no significant complications related to the intravenous immunoglobulin infusions. This study suggests that prophylactic immunoglobulin infusions will reduce the severity of CMV infection in the patient who is at risk for secondary or reactivation infection as well as the patient at risk for primary infection. This therapy should be considered for renal transplant recipients who are at high risk for developing CMV infection, both primary and secondary.

Adult↗

PubMed1990

Ureterocalicostomy for reconstruction of complicated pelviureteric junction obstruction.

Seven patients with complicated pelviureteric junction (PUJ) obstruction underwent reconstruction by means of ureterocalicostomy; 5 had undergone previous surgery and 2 had primary obstruction. Radiographic studies showed resolution or improvement of the obstruction in 5 patients, who remain asymptomatic 15 to 47 months (mean 30) post-operatively. Obstruction persists in 1 patient and the other developed renal artery thrombosis with subsequent loss of the kidney. It was concluded that ureterocalicostomy can provide long-term, successful reconstruction of a complicated PUJ obstruction, but significant complications may be associated with the procedure.

Adult↗

PubMed1989

Recent results of cadaver kidney retransplantation.

The results of secondary cadaver renal transplantation in 42 patients treated from 1980 to 1986 have been reviewed. The initial graft was from a cadaver donor in all cases. All patients were managed with a maintenance immunosuppressive regimen, including either antilymphoblast globulin and/or cyclosporine. The over-all 1 and 2-year patient survival rates were 97 and 94 per cent, respectively. The over-all 1 and 2-year graft survival rates were 69 and 63 per cent, respectively. Graft success was not influenced by patient age greater than 50 years, diabetes, initial graft removal, interval between initial graft removal and retransplantation, duration of initial graft function, level of presensitization or HLA-Dr antigen matching. Currently, cadaver renal retransplantation can be performed safely and with an improved opportunity for graft success. Patients who return to dialysis after losing an allograft should be encouraged to consider another transplant for the same reasons that prompted initial transplantation.

Adolescent↗

PubMed1989

Abdominal radiograph and renal ultrasound versus excretory urography in the evaluation of asymptomatic patients after extracorporeal shock wave lithotripsy.

A prospective study was done to compare the relative efficacy of an abdominal radiograph and renal ultrasound to excretory urography for the evaluation of asymptomatic patients 1 month after extracorporeal shock wave lithotripsy. We evaluated 101 renal units in 84 asymptomatic patients who had undergone extracorporeal shock wave lithotripsy 1 month previously with abdominal radiography, excretory urography and ultrasonography to evaluate the presence of retained stone fragments, dilatation of the collecting system and intrarenal or perirenal fluid collections or masses. The combination of abdominal radiography and ultrasonography identified retained fragments in 62 renal units, while excretory urography identified them in 54. Ultrasonography was less specific in identifying dilatation of part or all of the collecting system; proving falsely positive in 7 renal units and falsely negative in 14 compared to excretory urography. However, the case of obstruction was diagnosed correctly by both modalities. Finally, ultrasound appeared to be more specific and more sensitive in the evaluation of the presence of intrarenal or perirenal abnormalities. We conclude that a combination of abdominal radiography and ultrasonography is as good or better than excretory urography in identifying residual stone fragments and intrarenal or perirenal abnormalities. However, the finding of dilatation of all or part of the collecting system by ultrasonography is nonspecific and probably is better evaluated by excretory urography. We suggest that the routine radiological evaluation of asymptomatic patients 1 month after extracorporeal shock wave lithotripsy could be limited routinely to abdominal radiography and ultrasonography. However, when abnormalities of the collecting system are visualized on these studies excretory urography should be performed.

Adolescent↗

PubMed1989

Effect of captopril on urinary cystine excretion in homozygous cystinuria.

We determined if captopril could reduce urinary cystine excretion in homozygous cystinuric patients. Seven patients were treated with 150 mg. captopril daily after determination of baseline 24-hour urine cystine excretion. All patients had a history of multiple cystine stones, and were on chronic fluid and alkalization therapy. Five patients had previously been on D-penicillamine. Cystine excretion studies were repeated 1 to 5 months after institution of captopril. Baseline 24-hour urinary cystine excretion ranged from 580 to 970 mg. per gm. creatinine (mean 744). After institution of captopril these levels decreased to a range of 113 to 581 mg. per gm. creatinine (mean 371). These values on treatment represented a statistically significant decrease to between 18 and 89% of baseline levels (p equals 0.0045). We conclude that captopril can significantly, and at times profoundly, decrease urinary cystine excretion in patients with homozygous cystinuria. Further studies are required to elucidate fully the mechanism of urinary cystine reduction and to help define a possible role for this drug in routine maintenance or dissolution therapy.

Adult↗