Patient survival after renal transplantation; more than 25 years follow-up

Background: The determinators of patient survival after renal transplantation are incompletely known, and conflicting results hae been reported. This may have been influenced by time-related changes in patients selection, post-transplantation management and immunosuppressive regimens. This study was performed to evaluate in recipients of a first renal transplant the effect of patient characteristics, transplantation era, and the immunosuppressive regimen on patient survival. Method: We studied data from the Leiden Renal Transplant Database of all first renal transplantations performed between 1966 and 1994 in Leiden, the Netherlands. The effect of the following parameters on mortality was investigated: era of transplantation, sex, age at transplantation, cause of renal failure, immunosuppressive regimen, type and duration of pretransplantation dialysis, hypertension, diabetes mellitus, and smoking. In addition we analysed the causes of death. Results were expressed as crude mortality rates, relative risks of mortality, and standardized mortality ratios as compared with death rates in the Dutch population. Results: The analysis comprised 86 living donor transplant recipients and 916 cadaver transplant recipients. After adjustment for age and sex, the relative risk of morality for living donor transplant recipients compared with cadaver transplant recipients was 0.5 (95% CI 0.2 to 10.3, P=0.06). In the first cadaver kidney transplant recipients the risk of first-year mortality improved significantly with time, which coincided with the introduction of cyclosporin. The risk of mortality after the first year was higher in patients aged over 40 years at transplantation, men, smokers, and in the presence of hypertension or diabetes, but the effect of individual factors on mortality was small. We found no effect of the type of pretransplantation dialysis or the duration of pretransplantation haemodialysis on post-transplantation mortality. The standardized mortality ratio for recipients of first renal transplants was 14 times the population average in the first year after transplantation and was still four times in the remaining years. Conclusion: In the present study, time-related changes in patient management were responsible for improved patient survival in the first year after transplantation during the study period. Many individual factors contributed moderately to the risk of mortality after the first year. Compared to the general population the mortality rate of renal transplant recipients was significantly higher during the whole follow-up period.     

Brain macrophages synthesize interleukin-1 and interleukin-1 mRNAs in vitro

Amoeboid microglial cells (brain macrophages) were purified from early post-natal mouse brain cultures. The percentage of cells stained with an anti-Mac-1 antibody was greater than 95%. Stimulation of these brain macrophages by lipopolysaccharides induced the synthesis of interleukin-1 (IL-1), which, in part, remained associated with the cell surface and, in part, was released into the culture medium. In contrast, pure primary astrocyte cultures and cell lines of transformed or immortalised astrocytes did not synthesise significant amounts of IL-1, demonstrating that amoeboid microglia and not astrocytes synthesise IL-1 in vitro. These physiological data were confirmed by RNA hybridisation studies showing that, on LPS treatment, brain macrophages synthesise significant amounts of IL-1 alpha and IL-1 beta mRNAs.     

Acute Cholecystitis and Severe Ischemic Cardiac Disease: Is Laparoscopy Indicated?

BACKGROUND AND OBJECTIVES: Laparoscopy in patients with poor cardiac function has been the subject of controversy and is considered by many surgeons a relative contraindication. METHODS: We report the case of a patient who presented with acute cholecystitis and choledocholithiasis concurrent with unstable angina. Our experience in laparoscopic management of patients with calculous biliary disease and severe coronary artery disease is examined. RESULTS: The patient was managed by coronary angioplasty and stenting immediately followed by laparoscopic cholecystectomy and common bile duct exploration under close invasive hemodynamic monitoring and low-pressure pneumoperitoneum. Between 1996 and 2001, 39 patients with coronary artery disease and an ASA class of III or IV underwent laparoscopic cholecystectomy. Eight of these patients (20.5%) had common bile duct stones necessitating laparoscopic common bile duct exploration. No conversions were necessary, and no major morbidity or mortalities occurred. CONCLUSIONS: Laparoscopic cholecystectomy and common bile duct exploration can be safely performed in patients with severe ischemic cardiac disease under close hemodynamic monitoring and a low-pressure pneumoperitoneum (10 to 12 mm Hg).     

Management of unruptured incidentally found intracranial saccular aneurysms

Neurosurgical Review - Unruptured intracranial saccular aneurysms occur in 3–5% of the general population. As the use of diagnostic medical imaging has steadily increased over the past few...     

Cytotoxic Effect of Brain Macrophages on Developing

Brain macrophages are transiently present in different regions of the central nervous system during development or in the course of tissue remodelling following various types of injuries. To investigate the influence of these phagocytes on neuronal growth and survival, brain macrophages stemming from the cerebral cortex of rat embryos were added to neuronal primary cultures. A neurotoxic effect of brain macrophages was demonstrated by the reduction of the number of neurons bearing neurites within two days of contact between the two cell types. Neuronal death and phagocytosis were also directly observed in video recordings of living cultures. This toxicity involved the production by brain macrophages of reactive oxygen intermediates, as shown by the protective effect of catalase, a scavenger of H2O2. In addition, the respiratory bursts of brain macrophages were stimulated in the presence of neurons. These results suggest that brain macrophages could favour the appearance of neuroregressive events which occur either during neurogenesis or in neurodegenerative diseases, implying intracerebral recruitment of mononuclear phagocytes.     

Postoperative mortality a university Department of General Surgery: incidence of cardiac-related deaths

OBJECTIVES: To evaluate the incidence of cardiac deaths following noncardiac nonvascular surgery. STUDY DESIGN: Retrospective survey. PATIENTS: All patients undergoing mainly endocrinous and digestive surgery in a University department of general surgery between 1991 and 1996. METHODS: Analysis of all deaths occurring intra- and postoperatively, until discharge of the patients. Demographic and medical data, including patent myocardial ischaemia and risk factors for coronary artery disease, were recorded and compared with a control group including all patients undergoing surgery from January to September 1996. RESULTS: In the 8,700 patients who underwent mainly endocrine neck surgery (66%), or intra-abdominal surgery (31%), the mortality rate (n = 96) was 1.1% (95% confidence interval [95% CI] = 0.9-1.3%). Patent myocardial ischaemia or high risk factors for coronary artery disease were existing in 24% of patients with neck surgery, 31% of those with intra-abdominal surgery, and in 60% of the deceased patients (P < 0.01 vs control group). Those who died were older, were in a higher ASA physical class, and had undergone an emergency procedure more often than patients of the control group (P < 0.002 for each parameter). Two cardiac deaths, in patients with a patent cardiopathy, were recorded (cardiac mortality: 0.02%; 95% CI = 0.003-0.08%). The main cause of death was infection (n = 46), followed by haemorrhage (n = 12). Seven deaths remained unexplained. CONCLUSION: This study suggests that cardiac morbidity is a rare cause of death after noncardiac nonvascular surgery.