Results of living-related kidney transplantation in Puerto Rico

A total of 103 kidney transplantations from living-related donors were performed in the Puerto Rico Kidney Transplant Program between January 1977 and June 1984. The majority of these patients were male, 76% were between 21 and 50 years of age, 33% were indigent, and 38% were either black or of mixed race. Rigid exclusion criteria were established in the selection of kidney donors. All donor operations were at least 2-antigen-compatible. Surgical technique and posttransplant management were standard, except that in 1980 the immunosuppressive policy was changed as follows: posttransplant prednisone was very rapidly tapered to 20 mg/day at two weeks after transplantation and antilymphocyte globulin was used to treat all rejections. The overall 3-year patient survival for the 7 1/2 years is 91.6%, but after 1980 it increased to 98% perhaps a reflection of the changes in immunosuppressive policy. Eight of ten deaths were due to sepsis, most of them related to rejection treatment. The 3-year kidney survival was 77%. All kidney losses were due to rejection. A low incidence of urological complications is reported. There were no technical losses. A relatively low incidence of cancer is reported. Cutaneous mycosis is highly prevalent in our patients, but systemic fungi are virtually absent.     

Experience in the management of myelomeningocele in Puerto Rico

The medical records of 128 children with myelomeningocele who were treated at the Pediatric University Hospital, Puerto Rico Medical Center, from January, 1980, to July, 1985, were reviewed retrospectively. The medical and surgical management during the first hospitalization of these children was studied in detail for predefined parameters. The average age at the time of myelomeningocele repair was 6.6 days. Statistical analysis showed that repair of the myelomeningocele defect before 48 hours of age did not reduce the occurrence of ventriculitis. The incidence of ventriculitis secondary to the management of the myelomeningocele lesion was 12.5%. Complications after repair of the myelomeningocele (including skin flap necrosis, cerebrospinal fluid leaks, and wound infection) were present in 43.8% of the patients who developed ventriculitis and in 19.0% of those who did not. This observation is statistically significant (p = 0.03) and indicates that complications of healing after myelomeningocele repair represent the most significant risk factor for the development of ventriculitis.     

A marked increase in organ donation in Puerto Rico

During its first years of existence, the Puerto Rico Transplant Program barely reached 18 to 20 renal transplants per year. A brain death amendment to the law improved the numbers but only to a stable thirty/year. Polls and studies showed that, although people knew about transplantation and expressed willingness to donate, the powerful emotional grief reaction, as well as a peculiar decision-making process, all militated against effective donation. In 1995, LifeLink of Puerto Rico was created as part of the very successful LifeLink Foundation of Tampa, staffed by local professionals. Cadaveric donation increased exponentially by 1227% and in 2004, 22.4 donors per million population were recovered, up from 1.5, one of the steepest growth curves in the United States. As a result, kidney transplantation increased, a cardiac transplant program was inaugurated, a pancreas transplant program has started, and liver will follow. The success is the result of well-trained, culturally sensitive coordinators and requestors; continuous education to the public, hospitals, administrators, neurospecialists, and critical care units; hospital development; implementation of federal law; and a sensitive approach the deceased donor family, and not only to the waiting list patients. The results demonstrate that organizational and educational factors can override cultural obstacles.     

Interventional nephrology in Brazil: current and future status

The care of chronic kidney disease patients frequently involves many diagnostic and interventional procedures. Most of these procedures are currently performed by radiologists, vascular surgeons, and general surgeons. This has caused fragmented medical care, which has led many nephrologists to introduce a new paradigm, often referred as interventional nephrology (IN). The aim of this study was to establish the extent of involvement of the Brazilian nephrology community with regard to specific IN procedures. From October 2004 to February 2005, questionnaires were sent by e-mail to all 2500 nephrologists throughout Brazil. The enrollment questionnaire was composed of five sections, with questions about renal biopsy, specific training in ultrasonography, peritoneal dialysis access (insertion of peritoneal catheters guided or not by peritoneoscopy), hemodialysis vascular access (ability to place tunneled catheters, construction of arteriovenous fistulas, and other vascular access procedures), and the nephrologist's interest in being trained in IN. A total of 239 nephrologists answered the questionnaire. Only 18% of Brazilian nephrologists perform kidney biopsy guided by ultrasonography assisted by a radiologist. On the other hand, 42% of them reported that this procedure was done without any image support. Most of the respondents (85%) indicated that they were not formally trained to perform renal ultrasonography. When asked about peritoneal dialysis catheter placement, 66% of the respondents reported that they referred their patients to a surgeon for this procedure. The insertion of peritoneal dialysis catheters guided by peritoneoscopy was reported by 3% of the respondents. Similar to the results for peritoneal dialysis catheter placement, the majority of the respondents (77%) indicated no training in the insertion of tunneled catheters for temporary hemodialysis. Regarding the interest of nephrologists to participate in an IN program, the great majority (87%) responded that they would like to be trained in these procedures. Most nephrologists are not trained in IN procedures. Therefore, in Brazil, it will be necessary to develop training centers for IN that will allow nephrologists to optimize nephrology care.     

Some characteristics of recurrent calcium stone formers in Puerto Rico.

We have studied 83 patients with recurrent calcium stone formation in an attempt to determine an approximate incidence of metabolic disturbances associated with stone disease. Male veterans (n = 42), male non-veterans (n = 13), and women (n = 28) composed the group. We divided the groups in such fashion because they represented generally two distinct socioeconomic groups. Primary hyperparathyroidism was present in 19 per cent of the subjects; a marked predominance of women (15/16) was noted. Hypercalciuria of renal or intestinal origin was present in 23 per cent of the group. Of interest was a group of male veterans (17/83) in whom normocalciuria, normocalcemia, and normal serum phosphate were associated with high values of immunoreactive parathyroid hormone. These subjects had low urine phosphate. This set of findings indicates that these patients may be a new subgroup of stone-forming patients. Metabolic abnormalities could not be detected in 38 per cent of the patients. Classification of stone subjects is essential for rational management.     

Interventional nephrology in a federal hospital: economics of health care

Interventional nephrology is now an accepted subspecialty of nephrology that is revolutionizing the standard of care for renal failure patients. Interventional nephrology deals with the placement of tunneled cuffed catheters (TCCs) and maintenance of permanent vascular accesses, thus assisting in timely care. Prior to 2000 most end-stage renal disease (ESRD) patients from the Overton Brooks Veterans Affairs Medical Center (OBVAMC) were referred to an outlying hospital for TCC placement and endovascular procedures (EVPs) of permanent dialysis access. The referral process was cumbersome for the patients and expensive to the Medicine Service. OBVAMC started an interventional nephrology service in 2000. The current study reports the financial benefits of starting an interventional nephrology service at our institution. All procedures performed during the period from April 2000 to April 2004 were analyzed. The procedures were performed in the cardiac catheterization laboratory. The total payment (physician's and hospital fees) to the referral hospital for procedures prior to April 2000 was used to estimate the average savings to the Medicine Service over the last 4 years. A total of 129 TCCs and 43 EVPs were performed during this period. The estimated expense to OBVAMC would have been US dollars 603,978 for TCCs and US dollars 288,100 for EVPs based on charges prior to April 2000. The actual expense to the hospital, including facility fees and disposables, was US dollars 156,013. The net savings to OBVAMC over the last 4 years was US dollars 736,065. Interventional nephrology provided to a small population of renal failure patients in a tertiary federal health care facility has resulted in huge savings for the hospital. Increasing awareness of this procedural aspect of nephrology benefits not only the patients, but also helps ease the financial burden of ever-escalating health care costs.     

Renal resources on-line. Interventional nephrology resources on the Internet

Interventional nephrology is an emerging field in which the nephrologists themselves place and maintain accesses for dialysis. The number of patients on dialysis is increasing in the U.S., as are the number of accesses and related problems. The Internet is fast becoming a major source of information on this emerging field. Numerous teaching institutions offer information over the Internet and the volume of information is steadily increasing. Even though the Internet offers a great deal of information, the consumer must be cautious in using it as the information is not peer-reviewed and validated by regulatory agencies.     

Interventional nephrology: from episodic to coordinated vascular access care

In recent years, nephrologists have taken the initiative of performing vascular access-related procedures themselves. Because of their unique clinical perspective on dialysis access and better understanding of the intricacies of renal replacement therapy, nephrologists are ideally suited for this activity. This approach has minimized delays, decreased hospitalizations and decreased the use of temporary catheters, thereby improving medical care, decreasing costs and increasing patient convenience. Vascular access interventions commonly employed by nephrologists include vascular access education, vascular mapping, percutaneous balloon angioplasty, thrombectomy, intravascular coil and stent insertion and tunneled hemodialysis catheter-related procedures. While the performance of these procedures by nephrologists offers many advantages, appropriate training to develop the necessary procedural skills is critical. Recent data have emphasized that a nephrologist can be successfully trained to become a competent interventionalist. In addition to documenting excellent outcome data, multiple reports have demonstrated the safety and success of an interventional nephrology approach. The last decade has been a period of significant advances in this new field. This has been driven in part by the formation of the American Society of Diagnostic and Interventional Nephrology (ASDIN), whose mission includes training, quality assurance and certification. Recently, the ASDIN has published guidelines for training in nephrology-related procedures and has begun certifying physicians in specific procedures related to chronic kidney disease. It is anticipated that this will promote the skillful performance of these procedures by nephrologists and lead to substantial improvements in the care of renal patients. Challenges for the future include awareness of this subspecialty and development of training programs at academic centers on a larger scale.     

Long-term survival of patients with carcinoma of the esophagus in Puerto Rico.

From 1950 to 1971 a total of 4,342 cases of carcinoma of the esophagus were reported to the Central Cancer Registry of the Puerto Rico Health Department. Fifty-eight patients with histologic proof of their diagnosis survived five or more years, for an absolute survival of 1.3 per cent. Neither location of the tumor or type of treatment made much difference in average survival. In fact, 20 of the 58 patients had metastasis or extension of the tumor to adjacent tissues at sometime in their clinical course.     

Emigration From Puerto Rico to Florida: Multivariate Analysis of Factors That Condition Attitudes of the Puerto Rican Population Toward Organ Donation for Transplant

Background

The Puerto Rican population represents one of the largest immigration groups in Florida, and this has an impact on the organ transplant donation process. Our aim was to analyze attitudes toward organ donation among Puerto Ricans who currently reside in the state of Florida (USA).