The clinical usefulness of the renal allograft biopsy in the cyclosporine era: a prospective study

BACKGROUND: The renal allograft biopsy is generally accepted as the gold standard for clarifying the cause of renal dysfunction. However, the clinical usefulness of this procedure has rarely been studied prospectively, nor have most studies included follow-up of patients to delineate the influence of the biopsy on clinical outcome. In this study, we evaluated prospectively the clinical usefulness of the allograft biopsy in renal transplant recipients receiving cyclosporine (CyA). METHODS: During a 21-month period, 82 biopsies were performed. In 54 instances (47 patients), we outlined a presumed diagnosis and tentative treatment plan before the procedure. After the biopsy, a definitive diagnosis was made and an appropriate patient management approach was instituted. We analyzed the incidence of change in patient management that resulted from histological findings. All patients were followed to monitor their response to treatment and allograft survival. In cases of biopsy-proven acute cellular rejection (ACR) or cyclosporine (CyA) toxicity, clinical and laboratory data from the day of the biopsy were reviewed to determine their diagnostic value. RESULTS: One biopsy specimen was inadequate for definitive interpretation. The biopsy findings resulted in a change in patient management in 22 (41.5%) of the remaining 53 cases (change group). The incidence of altered patient management was 38.7% in biopsy specimens taken in the first month, 55.6% between 1 and 12 months, and 38.5% after 1 year posttransplantation. A change in management was required in 2 of 2 patients with chronic allograft dysfunction, in 44.4% of the 45 patients with acute allograft dysfunction, and in none of the patients with delayed graft function (n=6). Within the first week of treatment 19 of 22 (86.4%) in the change group and 25 of 31 (80.6%) in the no change group had a positive response to therapy. The 1-year allograft survival rate was also similar between the two groups. None of the clinical and laboratory data was useful in distinguishing ACR from CyA toxicity. CONCLUSIONS: Renal allograft biopsy findings alter patient management recommendations in approximately 40% of patients in whom a presumptive diagnosis had been made on the basis of clinical and laboratory findings. Patients who had a change in patient management because of biopsy findings demonstrated a response to therapy and allograft survival similar to those of patients who had no alteration in management plan after the biopsy.     

Evolving trends in liver transplantation: an outcome and charge analysis

BACKGROUND: Due to the limited supply and increased demand for donor livers, waiting times are progressively lengthening, which may lead to transplantation at more advanced and less cost-effective stages of disease. The purpose of this study was to evaluate the outcomes and hospital charges of liver transplantation during two recent eras to identify areas for providing more cost-effective care. METHODS: A total of 144 primary liver allografts were performed from 1991 to 1996. Patient characteristics, outcome measures, and hospital charges were compared for patients receiving allografts between 1991 and 1993 (group A) versus those receiving grafts between 1994 and 1996 (group B) using unpaired Student t tests for continuous data and chi-squared tests for categorical data. RESULTS: In comparing groups A and B, no significant differences in patient demographics, relative contraindications, or indication for transplantation existed; median waiting time from date of listing until transplant increased from 88 days to 159 days; and a shift in UNOS priority status at time of transplantation occurred, as the percentage of patients requiring inpatient care increased from 58% to 75% (P=0.034). Despite this, patient hospital and 1-year survival significantly improved from 75.0% to 90.3% (P=0.016), and from 68.1% to 88.9% (P=0.002), respectively. Total hospital charges, without correction for inflation, were $174,908+/-16,388 in A and $193,525+/-14,444 in B (P=0.288). The increased charges were associated with longer inpatient length of stay (LOS) before transplant, resulting in increased pretransplant charges from $24,088+/-4134 (A) to $39,490+/-6,196 (B) (P=0.011). Room and service (54%) was the largest pretransplant contributor to charges, while blood products (23%), room and service (21%), organ acquisition (13%), and operating room charges (11%) contributed the most after transplant. CONCLUSIONS: Longer waiting times resulting in transplantation at later stages of disease have occurred, leading to longer pretransplant LOS and its associated charges. Despite more advanced disease, patient survival rates have significantly improved with fewer infection-related deaths. LOS pretransplant, blood products, and operating room services represent potential areas for providing more cost-effective care.     

Clinical and prognostic characteristics associated with age and gender in acute myocardial infarction: A multihospital perspective in the Murcia region of Spain

Age and female gender have been associated with poor prognosis in acute myocardial infarction (AMI). Data currently available about the prognostic significance of gender in AMI might well have led to inappropriate/incomplete conclusions. A multicenter, prospective study on 1239 patients with AMI was conducted. Clinical characteristics, complications during the acute phase and one-year follow-up were monitored. Women constituted 24.1% of all patients. Female patients were older with more prevalence of diabetes, hypertension, and previous congestive heart failure. Compared with men, the following complications were more frequently found in women: heart failure, 43% vs. 22% (p<0.001); reinfarction, 5% vs. 2% (p<0.05); use of pacemaker, 7% vs. 4% (p<0.05). Women had higher mortality: early, during the first 24 hours post-admission, 10.7 vs. 3.1%; in-hospital, 23% vs. 8.1%; and 1-year, 33.7% vs. 16% (p<0.001 for all the 3 cases of mortality). In the age-groups considered (<65, 65–74, and 75 years), 1-year mortality increased exponentially with ageing in men: 7.8%, 21.3%, and 38.9%, whereas in women the figures were: 15.3%, 41.5%, and 38.8%. Multivariate analysis showed that, among other variables, age and female gender had independent prognostic value for in-hospital mortality whereas gender lost its prognostic significancy for 1-year mortality. Multivariate analysis restricted to those patients aged over 75 years showed that age but not gender had independent prognostic value. In conclusion, age and female sex have independent prognostic value for predicting mortality in patients with AMI. Mortality increases exponentially with ageing in men whereas it stabilises in the case of women over 65 years. Female gender loses its independent value for predicting mortality in patients over 75 years.     

Effect of antimicrobial and antineoplastic drugs on the uptake of fluconazole by human neutrophils and tissue culture cells

The effect of eight antimicrobial and three antineoplastic drugs on the uptake of fluconazole by human neutrophils and culture epithelial cells was evaluated. Fluconazole reached higher concentrations intracellularly than extracellularly (cellular to extracellular concentration ratio C/E 1.3) in the presence of therapeutical concentrations of the antimicrobial and antineoplastic agents evaluated.     

Friedreich's ataxia presenting with pure sensory ataxia: a long-term follow-up study of two patients

We describe two patients with Friedreich's ataxia whose presenting symptomatology was for years progressive tabetic ataxia. Based upon the initial clinical, electrophysiological and nerve biopsy data, a diagnosis of idiopathic sensory neuropathy was established. Subsequent examination of the kin showed that three sisters of case 1 had Friedreich's ataxia. Upon serial clinical and electrocardiographic study, both patients eventually developed a florid Friedreich's ataxia, including cardiomyopathy. Our findings indicate that at onset Friedreich's ataxia may be indistinguishable from sensory neuropathy and also that serial examination and investigation of kinship are essential steps for accurate diagnosis.     

The role of pancreatic venous sampling in the localization of occult insulinomas

The palpation and enucleation of occult insulinomas (less than 15 mm) can be a difficult surgical problem even with good arteriographic localization. In the authors' limited experience, confirmation of arteriographic findings by pancreatic venous sampling provided little additional localizing information. However, if arteriography is negative or equivocal, venous sampling can indicate the segment of pancreas to be "blindly" resected if the adenoma is not palpable. Venous sampling may be misleading in polyendocrine syndromes because of the frequency of multiple adenomas and variable hormone production.     

Results of surgical treatment of hepatic hydatidosis: Current therapeutic modifications

Hepatic hydatidosis is an endemic disease that affects vast segments of the populations of various countries in the Mediterranean region, South America, the Pacific, and temperate zone nations that possess large numbers of sheep. Four hundred and ten patients bearing 561 hydatid cysts were treated at 2 major hospitals in Madrid, Spain in the period 1974–1989. In order to establish the modifications in diagnostic and therapeutic management introduced as a result of modernization of our clinical facilities and improved technological standards, they were divided into 2 groups: group A corresponded to the period 1974–1984, and group B, corresponded to the period 1985–1989. Since no effective parasiticide agent is available, hepatic hydatidosis must be treated surgically. Today's better knowledge and advancements in liver surgery have made it possible to extirpate the cyst completely with little risk and improved results; hepatic resection should only be considered in exceptional cases; aspiration, drainage procedures, or partial resections of the cyst yield inferior results. We have had no relapse of the hydatid disease in the liver or in any other abdominal site.

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Resumen La hidatidosis hepática es una enfermedad endémica que afecta a vastos segmentas de las poblaciones de diversos países de la región mediterránea, Sur América, el Pacífico, y las naciones de las zonas templadas que mantienen grandes rebanos de ovejas. Cuatrocientos diez pacientes con 561 quistes hidatídicos fueron tratados en 2 grandes hospitales de Madrid, España en el período 1974–1989. Con el propósito de establecer las modificaciones en el manejo diagnóstico y terapéutico ocurridas como resultado de la modernización de nuestras facilidades clínicas y de superiores estándares tecnológicos, dividimos la población total de estos pacientes en 2 grandes grupos: grupo A, correspondiente al período 1974–1984, y grupo B, correspondiente al período 1985–1989. Puesto que no existe un agente parasitocida efectivo, la hidatidosis hepática debe ser tratada quirúrgicamente. El mejor conocimiento actual y el avance en la cirugía hepática han hecho posible la extirpatión completa del quiste con bajo riesgo y mejores resultados; la resection hepática debe ser considerada sólo en casos excepcionales; la aspiración, los procedimientos de drenaje o las resecciones parciales del quiste se asocian con malos resultados. En nuestra experiencia no hemos tenido recurrencia de la enfermedad ni en el hígado ni en otros órganos.

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Résumé Le kyste hydatique du foie est une maladie endémique qui touche une partie importante de la population dans différents pays de la région méditerranéenne, en Amérique du Sud, dans le Pacifique, et dans les pays de la zone tempérée qui ont beaucoup de moutons. Quatre cent dix patients porteurs de 561 kystes hydatiques ont été traités dans les deux plus grands hôpitaux de Madrid en Espagne de 1974 à 1989. Pour mesurer les progrès dans le diagnostic et le traitement dus à la modernisation de notre équipement médical et à une meilleure technologie, les patients ont été divisés en 2 groupes chronologiques: groupe A de 1974 à 1984 et groupe B de 1985 à 1989. Comme il n'y a pas actuellement de médicament efficace contre ce parasite, on doit traiter par la chirurgie le kyste hydatique. Aujourd'hui, les connaissances plus étendues et les progrès dans la chirurgie du foie permettent d'enlever complètement le kyste avec peu de risques et avec de meilleurs résultats; la résection du foie ne doit être envisagée que dans de rares cas. Les procédés d'aspiration ou de drainage ou les résections partielles du kyste donne des résultats moins bons. Nous n'avons pas eu de récidive du kyste hydatique, ni au foie ni dans une autre localisation péritonéale.

     

Release of noradrenaline by the ionophore X537A from normal and reserpinized guinea-pig atrium

Summary The effects of ionophore X537A on the release of ³H-noradrenaline and its metabolites from the superfused guinea-pig left atrium were investigated. Concentrations of ionophore of 10 and 30 M greatly increased the release of tritium. Of the total increase in radioactivity elicited by X537A 44% was accounted for as noradrenaline and 50% was due to deaminated metabolites. The ionophore-evoked release of tritium was independent of the extracellular calcium ions and was not affected by agents which modify calcium movements such as verapamil, ryanodine, ruthenium red and tetracaine. X537A released ³H-noradrenaline from extragranular sites in MAO-inhibited atria from reserpine-treated animals and this release was also calcium independent. It is concluded that the ability of X537A to release noradrenaline from vesicular or cytoplasmic sites is not related to its ability to couple with and transport calcium ions through membranes. The ionophore might modify the ionic distribution outside and inside the neuronal membrane which would lead to leakage of the transmitter.