Resection of large inferior vena caval thrombi from renal cell carcinoma with the use of circulatory arrest

Removal of a large extension of renal cell carcinoma into the inferior vena cava can be a difficult operation. Circulatory arrest is an operative technique that recently has been used to assist in resection of tumors that extend into the vena cava above the level of the hepatic veins. At our clinic 18 patients were operated on with the intent of using circulatory arrest during radical nephrectomy and inferior vena caval thrombectomy. Of the 18 patients 13 ultimately underwent this procedure, since the remaining 5 had unresectable tumors. One patient died intraoperatively of an adverse reaction to protamine after technically successful removal of the tumor and thrombus. Resection was successful in 12 patients and 9 remained free of disease with short followup. We believe that the addition of circulatory arrest during resection of a large inferior vena caval thrombus allows for an opportunity to resect the tumor in a controlled situation that reduces the potential for sudden massive blood loss or a major vascular injury, and ultimately makes the operation safer.     

Flank donor nephrectomy: efficacy in the donor and recipient

Since August 1983, 115 patients have undergone live donor nephrectomy via an extraperitoneal flank approach with rib resection. Over-all hospital stay was short and morbidity was negligible. Early graft function was excellent as determined by urinary output in the first 20 hours postoperatively (mean 6,442 cc) and low nadir serum creatinine (mean 1.57 mg. per dl.). Acute tubular necrosis or urinary fistula developed in 3 kidneys (2.6 per cent). In the entire series, only 1 graft (0.8 per cent) was lost to technical complications. We conclude that an extraperitoneal flank approach to live donor nephrectomy is safe for the donor, and provides a structurally and functionally sound allograft for the recipient.     

Use of kidneys from older cadaver donors for renal transplantation

This study was undertaken to investigate the suitability of kidneys for transplantation from elderly cadaveric donors, and to identify those factors that were associated with a successful outcome, i.e. immediate graft function and function at one year. From 1977 to 1990, 51 kidneys from cadaveric donors at least 55 years of age were employed for transplantation. Donor age ranged from 55 to 70 years. The most common causes of donor death were intracerebral hemorrhage (60%) and cerebrovascular accident (36%). The donor serum creatinine levels upon hospital admission and at organ procurement ranged from 0.6 to 2.0 mg/dl and from 0.5 to 4.0 mg/dl, respectively. Donor urine outputs immediately prior to procurement ranged from 55 to 3,000 mls per hour. Fifty kidneys (98%) were transplanted within 48 hours of procurement. The recipients ranged in age from 8 to 68 years (median 42). Posttransplant immunosuppression comprised prednisone and azathioprine in all patients along with ALG in 34 patients, OKT3 in 9 patients and cyclosporine in 35 patients. Following transplantation, 19 grafts (37%) functioned immediately while 32 (63%) did not function initially; of the latter, 24 functioned eventually and 8 (16%) never functioned. The overall one-year graft survival rate was 72%, which is somewhat less than our current center rate of 85% for all cadaveric renal transplants. There was no significant correlation between graft outcome and recipient age, HLA matching, level of presensitization, blood group, preservation time, or CMV status. Both immediate graft function (p = 0.001) and one-year graft survival (p = 0.01) were significantly influenced by the donor serum creatinine level; in both cases, a donor serum creatinine less than 1.2 mg/dl was associated with a successful outcome. These data indicate that older donor age per se should not contraindicate cadaver renal procurement for transplantation.     

Conventional immunosuppression after deliberate third party transfusions versus cyclosporine in living related renal transplant recipients

A total of 93 recipients of either HLA-identical (34) or 1-haplotype matched (59) living related donor renal transplants was assigned prospectively into immunosuppressive treatment groups on the basis of transfusion histories obtained at the initial evaluation for transplantation. Patients who received 0 to 2 third party transfusions were given no further transfusion, and received cyclosporine and prednisone immunosuppression after transplantation (cyclosporine group). Patients who received 3 or 4 third party transfusions were given additional transfusions until 5 had been received, and were managed with azathioprine and prednisone after transplantation (azathioprine group). Patients who already received 5 or more third party transfusions had no additional transfusions and were assigned to the azathioprine group. No patient had a positive crossmatch to the potential donor after initial evaluation and confirmation of a negative crossmatch. The number of rejection episodes per patient after transplantation was significantly higher in the azathioprine group for HLA-identical (p equals 0.001) and 1-haplotype (p equals 0.003) recipients. One-year patient survival rats for the HLA-identical cyclosporine and azathioprine groups were 100 and 94 per cent, respectively, with respective 1-year allograft survivals of 100 and 89 per cent in the 2 groups. In the 1-haplotype group 1-year patient survival rates were 95 and 94 per cent for the cyclosporine and azathioprine groups, respectively; allograft survival was 81 per cent for the cyclosporine group and 91 per cent for the azathioprine group. None of the observed differences in graft or patient survival between the 2 groups was statistically significant. Deliberate third party transfusions with conventional immunosuppression and cyclosporine immunosuppression are effective methods to treat recipients of living related donor renal transplants.     

环孢菌素A阻断人HL-60抗药性细胞于G1期而诱导敏感细胞凋亡

进一步研究了抗三尖杉酯碱的HL-60细胞(HR20)抗细胞凋亡的机制及该抗性和抗药性的关系。结果表明,环孢菌素A(CsA)20,10μg·ml^-1诱导HL-60细胞发生凋亡,而阻断HR20细胞于G₁期,就不能诱导细胞发生凋亡。低浓度的CsA明显增加柔红霉素在HR20细胞内的积聚,其逆转抗药性作用与阻断细胞周期运行无关。CsA10μg·ml^-1处理HR20细胞,可引起50kDa的蛋白质高度磷酸化。结果提示:环孢菌素A阻断抗三尖杉酯碱的HL-60细胞于G₁期,而诱导敏感的HL-60细胞发生凋亡,其阻断作用与抗药性无关。     

Portal radiographs: digital enhancement of contrast

The quality of low-contrast portal radiographs for radiation therapy can be improved with electronic contrast enhancement. After the image is copied digitally with a laser scanner microdensitometer into 4,096 gray-scale levels (12 bits) and 1,686 X 2,048 pixels, a special software package permits linear, logarithmic, exponential, or sigmoid transformations of the optical density. The precise representation of the portal image can then be interactively adjusted to emphasize the desired anatomy. Clinical examples demonstrate the value of the digital enhancement approach.