Outcome of pediatric renal transplants in a developing country

This study was conducted to evaluate the outcome of pediatric renal transplants at our center. A retrospective analysis was done on 39 pediatric transplants (age at transplant <18 years) done at our center over the last 10 years. The mean age at transplant was 15.6±1 years (10–17 years). They comprised 4.2% of all renal transplants done at our center (39/921) over the period. Girls comprised 17.5% of total recipients (n=7). Two patients had a preemptive transplant. The underlying causes of end stage renal disease were chronic glomerulonephritis (n=21), chronic interstitial nephritis (n=17) and Alport syndrome [1]. All the 39 children were initiated on triple drug immunosuppression (cyclosporin A (CsA) azathioprine, prednisolone). All patients received grafts from living related donors. In the first month, three patients had graft loss (serum creatinine, SCr, >5 mg/dl). Of these, two patients died because of septicemia and one had acute cortical necrosis. There was evidence of infection in 16 patients (40%). Acute rejection was seen in 17 patients (45.8%). The 1-year patient and graft survival was 89% and at 3 years 70%. The actuarial graft survival at 5 years was 50%. Twelve children discontinued CsA after 1 year post-transplant and five of these had graft loss. Graft losses were significantly greater in patients who discontinued CsA as compared to those who continued CsA (5/12 vs 2/22). After a mean follow-up of 31.5±3.5 months, of the 37 patients, 10 had graft loss and chronic graft dysfunction was observed in another 9 patients. The rest of the 17 (48%) patients had a mean SCr of 1.2 mg/dl. The long-term outcome of pediatric renal transplants in our country remains suboptimal. CsA discontinuation due to financial constraints and/or non-compliance remain the most important reasons for this.     

Normobaric hyperoxia reduces MRI diffusion abnormalities and infarct size in experimental stroke

BACKGROUND: Hyperbaric oxygen therapy is considered an important stroke treatment strategy. BACKGROUND: To determine whether normobaric oxygen is neuroprotective, and, if so, what the therapeutic time window is. METHODS: Experiment 1-Serial diffusion- and perfusion-weighted MRI (DWI and PWI) was performed after middle cerebral artery filament occlusion (MCAO) in rats randomized to FiO(2) 30% (normoxia) or FiO(2) 100% (hyperoxia). Experiment 2-48-hour lesion volumes were analyzed in rats subjected to 2-hour MCAO and randomized to normoxia or hyperoxia starting 15, 30, or 45 minutes after MCAO and ending 15 minutes after reperfusion. RESULTS: Experiment 1-Lesion apparent diffusion coefficient (ADC) values were persistently low in normoxic animals. In hyperoxia-treated rats, ADC values in cortical border zones showed progressive recovery from 66 +/- 3% of contralateral before hyperoxia, to 104 +/- 20% at approximately 2 hours. Striatal ADC values showed early but ill-sustained improvement. ADC lesion volumes increased progressively in the normoxia group. In the hyperoxia group, ADC lesion volumes tended to decrease after starting hyperoxia; however, lesions later increased in size, and 2-hour lesion volumes were not significantly different from baseline. PWI showed stable right MCA hypoperfusion in all animals. Experiment 2-Hyperoxia within 30 minutes significantly reduced total and cortical lesion volumes at 48 hours after stroke. Striatal lesion volumes were significantly reduced in the hyperoxia-15 group. CONCLUSION: In rats subjected to transient stroke, 100% oxygen administered within 30 minutes salvages ischemic brain tissue, especially in the cerebral cortex. Reducing the time to treatment enhances the degree of neuroprotection.     

Is povidone iodine an alternative to silver nitrate for renal pelvic instillation sclerotherapy in chyluria?

OBJECTIVE: To compare the efficacy and toxicity of 1% silver nitrate, 0.2% povidone iodine and 50% dextrose in renal pelvic instillation sclerotherapy (RPIS) for chyluria. PATIENTS AND METHODS: In a prospective randomized comparative study from January 1999 to June 2003, 106 patients (61 males and 45 females; mean age 36 years, sd 12, range 14-65) were randomized to receive 1% silver nitrate, 0.2% povidone iodine or 50% dextrose as RPIS. In all, nine doses were given at 8-h intervals, and patients followed at 6 weeks and then at 3-monthly intervals. Patients with 'persistence' or 'recurrence' of chyluria were treated with second course of RPIS using same sclerosant. RESULTS: The dextrose treatment was discontinued at mid-term because of poor success (one of 21 patients, P < 0.001). Of 85 patients, 44 received silver nitrate and 41 povidone iodine; both groups were well-matched and the mean follow-up was 28.4 and 23.3 months, respectively. 'Immediate clearance' was recorded in 91% and 98%, and recurrence in 21% and 22% of patients after the first course of RPIS, after silver nitrate and povidone, respectively; Kaplan-Meier estimates of 'disease-free duration' in the two groups (23.6 vs 20.1 months) were also similar (P = 0.7906). The cumulative success rate after two courses of RPIS was 82% (silver nitrate) and 83% (povidone; P = 1.0). Five (11%) patients in the silver nitrate and one (2%) in the povidone group had significant flank pain during treatment. CONCLUSIONS: Povidone iodine 0.2% is as effective for RPIS as 1% silver nitrate.     

Safety profile and complications of transperitoneal laparoscopic pyeloplasty: a critical analysis

PURPOSE: To critically assess the safety profile and complications of the transperitoneal approach to laparoscopic pyeloplasty at our center. PATIENTS AND METHODS: From January 2002 to January 2004, 92 patients with a mean age of 22.78 +/- 15.15 years (range 14 months-65 years) with primary (N = 90) or secondary (N = 2) ureteropelvic junction obstruction were treated by transperitoneal laparoscopic pyeloplasty and were evaluated for this study. Renal stones were present in eight patients. A double-J stent was placed antegrade in 50 patients and in the rest through cystoscopy. All patients were followed up clinically and by renal scan. RESULTS: Of the 92 cases (93 renal units), 6 were converted to open pyeloplasty. Dismembered pyeloplasty was performed in 59, Fengerplasty in 8, and Foley Y-V-plasty in 20 units. A crossing vessel was present in 15 units (16.12%). The mean estimated blood loss was 63.6 mL (range, 30-200 mL). The mean operative time was 179.4 minutes (range 80-350 minutes). Overall, 17 patients (18.4%) had complications. Six patients had paralytic ileus and another six had increased drain output, which delayed the hospital stay to 7 days. Pyelonephritis and port-site hernia occurred in one patient each. Four patients required ancillary procedures: ureteroscopy for a migrating stent (1), percutaneous antegrade stenting (1), and SWL for residual stone (2). The mean hospital stay was 4 days (range 2-7 days). Of the 87 units (86 patients), 81 (93.3%) have shown improvement in symptoms and drainage pattern on renal scan at a mean followup of 12 (3-27) months. CONCLUSION: The transperitoneal approach to pyeloplasty is safe and effective, although patients with large stone bulk and multiple stones should be considered for an alternative approach. The double-J stent should be checked carefully for proper placement. Hemostasis of the cut margin of the renal pelvis, watertight anastomosis, and adequate drainage should also be ensured.     

CAN OUTCOME OF INTERNAL URETHROTOMY FOR SHORT SEGMENT BULBAR URETHRAL STRICTURE BE PREDICTED?

PURPOSE: We predicted the outcome of visual internal urethrotomy (VIU) by measuring the percentage of lumen narrowing at the stricture site on retrograde urethrography (RGU). MATERIALS AND METHODS: From January 1991 to June 2002 patients with primary bulbar urethral strictures who underwent VIU were selected for the study. Patients with a history of intervention, complete block of the urethral lumen and stricture greater than 2 cm were excluded from study. Urethral diameter at the area of maximum stenosis and at the normal distal urethra was measured on RGU with Vernier caliper and percentage narrowing was derived. Patients were followed 3 times monthly with symptoms, calibration and whenever required with RGU. Recurrence of symptoms, failure to self-calibrate and the need for secondary procedure were considered treatment failure. RESULTS: Complete followup data were available in 105 patients (44 grade 1 and 61 grade 2). Mean bulbar urethral stricture length was 0.86 cm. Inflammation was the cause of stricture in 83 (79%) and trauma the cause in 22 (21%) patients. In the Cox proportional hazards model only grade of narrowing had a significant impact on outcome. There were 41 cases of treatment failure in the total followup of 46 +/- 9 months. Mean recurrence-free duration +/- SD was 13 +/- 15 and 44.52 +/- 19 months in cases of treatment failure and success, respectively (p <0.0001). Mean percentage narrowing was significantly higher with treatment failure (69.9% +/- 16.1% vs 48.55% +/- 17.3%, p <0.0001). A cutoff of 74% for urethral narrowing was derived to predict the outcome with 78% probability. CONCLUSIONS: Percentage narrowing of the urethral lumen at the stricture site is a useful predictor of VIU outcome.     

Thyroid abscess—an acute emergency

An abscess in a long-standing goitre is usually life threatening. A patient with a large goitre was lost to follow-up for about 10 years and presented with a large thyroid abscess causing acute respiratory obstruction. The abscess caused erosion of the tracheal wall and perforation of the esophagus. Clostridium septicum was the causative organism, which is almost always associated with cancer of the colon. This led to the detection of colonic malignancy in this patient on further investigations. We describe the complications of a thyroid abscess and discuss the pathophysiology and treatment.     

Retroperitoneal ganglioneuroma presenting as right renal mass

A primary retroperitoneal ganglioneuroma was found in a 37-year-old woman on computed tomography, which revealed a homogeneous mass just above the right kidney. The tumor was resected through a transabdominal approach. The resected specimen measured 11 x 9 x 4.5 cm and weighed 270 g. The histologic examination showed that the lesion was a ganglioneuroma composed of both mature ganglion cells and nerve fibers.