Outcome of Patients with Diabetic Nephropathy after Kidney Transplantation

ABSTRACT During the period 1973–1983, 1014 patients with end stage renal failure received a kidney graft at the Helsinki University Central Hospital. As a consequence of diabetic nephropathy, 163 of them (16%) developed renal failure. Ten diabetic (6%) and 72 non-diabetic (9%) patients received grafts from a living donor. One-year patient survival did not differ between diabetic and non-diabetic patients (76% and 79%, respectively). From the second post-transplant year onwards patient survival was worse in diabetic than in non-diabetic patients. The two groups did not differ with respect to graft survival. Sixty-two diabetic patients (38%) died during the follow-up period, with myocardial infarction as the most common cause of death (31%), followed by infection (15%) and cerebral stroke (13%). Seven myocardial infarctions out of 19 occurred within three months of transplantation. However, significantly more fatal and non-fatal myocardial infarctions were observed in post-transplant patients who had returned to dialysis therapy than in patients with a functioning kidney graft. Blindness did not influence the outcome of transplantation. Nor did the transplantation significantly affect the course of this diabetic complication. In conclusion, although the early success rate of kidney transplantation in our study population was acceptable, the later outcome was poor, mainly due to advanced disease-related complications.     

Detection of factor VIII inhibitors with the partial thromboplastin time

Variations of the partial thromboplastin time (PTT) were tested to determine the best screening method for detection of inhibitors of factor VIII. Variables tested included the duration of preincubation of a mixture of patient plasma and factor VIII source (normal plasma), the ratio of the patient plasma to the normal plasma, and the duration of incubation of the normal plasma-patient plasma mixture with kaolin- cephalin suspension prior to recalcification. The following conclusions were reached: (1) The PTT performed on a mixture of equal amounts of patient and normal plasma without preincubation of the mixture was inadequate to detect many factor VIII inhibitors. (2) Factor VIII inhibitors of more than 0.5 Bethesda units could be detected if the PTT was performed on a mixture of four parts patient plasma and one part normal plasma, with preincubation of the mixture for 60 min at 37 degrees C. (3) Factor VIII inhibitors as weak as 0.1 Bethesda units could be detected if the PTT was performed on a mixture of four parts patient plasma and one part normal plasma incubated with kaolin- cephalin suspension for 120 min at 37 degrees C before recalcification. The last method may make detection of mild factor VIII inhibitors possible in routine clinical laboratories not equipped to perform the more technically difficult Bethesda inhibitor assays.     

Routine use of arteriovenous fistula construction to dilate the venous outflow prior to insertion of an expanded polytetrafluoroethylene (PTFE) loop graft for dialysis

For long-term haemodialysis to be successful an adequate lengthof vessel with correspondingly high flow is necessary, and theuse of a peripheral arteriovenous fistula (AVF) between brachialartery and median cephalic vein is well described for long-termvascular access. However, the length of vessel available isoften insufficient for dialysis and the time-lag between formationand availability for use may be prolonged. Primary insertionof a PTFE interposition graft is an alternative but may be technicallydifficult due to the small diameter of vein available for run-off,resulting in a significant rate of thrombosis. We advocate earlyAVF formation in most patients, even where the fistula is unlikelyto prove usable for dialysis, with the express purpose of dilatingthe veins prior to PTFE graft insertion. The time-lag betweenAVF formation and PTFE graft insertion may be as short as 1week. Although conversion of a functioning AVF to PTFE interpositiongraft has been described by others, we believe the routine useof AVF formation prior to PTFE insertion has not been previouslyadvocated and gives a considerable advantage in patients withdifficult dialysis access.