RESUMEN
PURPOSE: To determine whether the Wallstent endoluminal prosthesis can be used to maintain patency of venous stenoses and occlusions related to hemodialysis access. MATERIALS AND METHODS: Wallstents were placed in 52 patients with 56 lesions. Thirty-two lesions were in central veins and 24 were in peripheral veins. Stents were placed immediately after failed angioplasty in 39 patients, because of early restenosis after angioplasty in four, and for treatment of a lesion unsuitable for angioplasty in eight. The remaining five lesions were treated at the operator's discretion after predilation. RESULTS: The procedural success rate was 96%. The cumulative primary patency rate was 46% at 6 months and 20% at 12 months; however, with repeat treatment, the cumulative assisted patency rate was 76% at 6 months and 33% at 12 months. Known causes of recurrence included intimal hyperplasia in or near the stent, stent slippage, and remote stenoses. Complications included two stent migrations due to central line placement and one stent-related pseudoaneurysm. CONCLUSION: Wallstents are safe to deploy for dialysis access. Wallstents are useful for treating lesions that fail angioplasty and catheter-related central venous occlusions.
Asunto(s)
Angioplastia de Balón , Oclusión de Injerto Vascular/terapia , Diálisis Renal , Stents , Derivación Arteriovenosa Quirúrgica , Prótesis Vascular , Constricción Patológica/diagnóstico por imagen , Constricción Patológica/terapia , Femenino , Estudios de Seguimiento , Oclusión de Injerto Vascular/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Recurrencia , Insuficiencia del Tratamiento , Grado de Desobstrucción VascularAsunto(s)
Bioética , Cadáver , Ética Médica , Donantes de Tejidos/provisión & distribución , Obtención de Tejidos y Órganos/organización & administración , Trasplante , Centers for Disease Control and Prevention, U.S. , Muerte , Urgencias Médicas , Familia , Cuerpo Humano , Humanos , Preservación de Órganos , Estados UnidosAsunto(s)
Paro Cardíaco , Trasplante de Riñón/métodos , Donantes de Tejidos , Animales , Cadáver , Perros , Humanos , Riñón/fisiología , Perfusión/métodos , Circulación RenalAsunto(s)
Trasplante de Riñón/inmunología , Muromonab-CD3/efectos adversos , Adulto , Presión Sanguínea , Cadáver , Femenino , Humanos , Terapia de Inmunosupresión/métodos , Periodo Intraoperatorio , Trasplante de Riñón/fisiología , Masculino , Morbilidad , Muromonab-CD3/administración & dosificación , Muromonab-CD3/uso terapéutico , Pulso ArterialAsunto(s)
Suero Antilinfocítico/uso terapéutico , Trasplante de Riñón/inmunología , Muromonab-CD3/uso terapéutico , Azatioprina/uso terapéutico , Cadáver , Ciclosporina/uso terapéutico , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Terapia de Inmunosupresión/métodos , Tiempo de Internación , Metilprednisolona/uso terapéutico , Estudios RetrospectivosAsunto(s)
Trasplante de Riñón , Obtención de Tejidos y Órganos , Factores de Edad , Antígenos de Grupos Sanguíneos , Cadáver , Familia , Estudios de Seguimiento , Supervivencia de Injerto , Prueba de Histocompatibilidad , Humanos , Terapia de Inmunosupresión/métodos , Trasplante de Riñón/inmunología , Donantes de TejidosRESUMEN
Previous studies have shown a protective effect of trifluoperazine (TFP), a calmodulin inhibitor, upon the microcirculation of cold-stored kidneys. The present study points to similar beneficial effects of TFP on the microcirculation of cold-stored livers; 25 canine livers were preserved for 24 hr with Euro-Collins' solution (EC) (n = 8), University of Wisconsin solution (UW) (n = 7), or UW + TFP (n = 10). The stored livers underwent heterotopic transplantation (HLTX); hepatic-artery and portal-vein pressure and flow were monitored; oxygen consumption and extraction were measured before HLTX and at 15-min intervals after reperfusion, for 1 hr. Mean hepatic-artery and portal-vein flow (HAF & PVF) prior to donor hepatectomy were 172 and 530 cc/min, respectively. Poor HAF and PVF occurred in EC-HLTX (mean 35, 175 cc/min, respectively). The damaged EC-flushed livers could not compensate to the decreased hepatic blood flow by increased oxygen extraction (oxygen consumption and extraction, 8.7 vol.% and 48%, respectively). Light and electron microscopy showed severe liver necrosis and periportal hemorrhages. Improved hepatic-artery and portal-vein flows were seen in UW HLTX (105 and 254 cc/min), and oxygen consumption and extraction were 16.4 vol.% and 66%, respectively. Liver biopsy taken just before reperfusion revealed well-preserved liver architecture. Liver biopsy obtained 1 hr after reperfusion revealed marked edema of the portal triad, sinusoid congestion, and hemorrhage. Electron-microscopy biopsies obtained during reperfusion at 15-min intervals revealed severe vasospasm of the terminal hepatic arterioles and progressive damage to the liver microcirculation. The addition of TFP to the UW-flush solution resulted in excellent protection of the liver microcirculation. Marked increase in hepatic-artery and portal-vein blood flow was noted after reperfusion (mean 167 and 421 cc/min, respectively (P 0.02 vs. UW: P 0.001 vs. EC). The recovery of metabolic activity was evident by the high oxygen consumption and extraction (25.8 vol.% and 80%, respectively). And serial liver biopsies obtained after reperfusion have shown excellent protection of liver architecture and the absence of hepatic arteriolar vasospasm. Taken together, these data suggest that the addition of TFP to the UW solution protects the liver microcirculation by rendering the hepatic microcirculation insensitive to vasospastic stimuli during reperfusion, thus permitting better metabolic recovery after transplantation.
Asunto(s)
Circulación Hepática/efectos de los fármacos , Trasplante de Hígado , Soluciones Preservantes de Órganos , Preservación de Órganos , Trifluoperazina/farmacología , Adenosina , Alopurinol , Animales , Calcio/fisiología , Frío , Perros , Glutatión , Insulina , Microcirculación/efectos de los fármacos , Consumo de Oxígeno , Rafinosa , Reperfusión , SolucionesAsunto(s)
Trasplante de Riñón/fisiología , Circulación Renal , Biopsia con Aguja , Creatinina/sangre , Ciclosporinas/uso terapéutico , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Trasplante de Riñón/inmunología , Metilprednisolona/uso terapéutico , Preservación de Órganos , Prednisona/uso terapéutico , Obtención de Tejidos y Órganos , Trasplante HomólogoAsunto(s)
Comparación Transcultural , Países en Desarrollo , Ética Médica , Donantes de Tejidos/legislación & jurisprudencia , Obtención de Tejidos y Órganos/legislación & jurisprudencia , Trasplante/legislación & jurisprudencia , Comercio/legislación & jurisprudencia , Humanos , Asignación de Recursos , Donantes de Tejidos/provisión & distribución , Estados UnidosRESUMEN
We report a case of refractory bladder fistula in a diabetic renal allograft recipient that recurred shortly after conventional operative repair without any detectable external cause. After reoperation and use of a vascularized rectus muscle flap the fistula closed and the patient has retained excellent graft function. It is suggested that this technique should be considered as the primary repair modality for bladder fistulas in diabetic recipients, when wound healing is impaired seriously as a consequence of the combined effects of diabetic microangiopathy and steroid therapy.
Asunto(s)
Trasplante de Riñón , Colgajos Quirúrgicos , Fístula de la Vejiga Urinaria/cirugía , Adulto , Diabetes Mellitus Tipo 1/cirugía , Nefropatías Diabéticas/cirugía , Humanos , Masculino , Complicaciones Posoperatorias/cirugía , Recurrencia , Reoperación , Fístula de la Vejiga Urinaria/etiología , Cicatrización de HeridasRESUMEN
Effective utilization of nonheartbeating cadaver donor organs is limited by the time required to obtain the necessary family consent prior to organ retrieval (a delay of at least 4-6 hr); this exceeds by far the maximum tolerance of kidneys to warm ischemia. Measures that could theoretically permit use of such organs include: (1) rapid in situ flush cooling; (2) continued in situ kidney cooling until permission for donation is secured; and (3) cell-membrane stabilization of vital organs, with only minimal invasion of the donor body. These measures were tested experimentally in dogs. Hemorrhagic shock was produced in mongrel dogs. One hour after cessation of heartbeat, a rapid perfusion tube was placed into the femoral artery; it was advanced, and its balloon was inflated in the aorta above the renal vessels. The kidneys were then flushed in situ with 1000 cc of cold preservation solution containing a calmodulin inhibitor, trifluoperazine. Two other catheters were inserted percutaneously into the peritoneal cavity for continuous intraperitoneal cold perfusion. Core temperatures of 4 degrees C were maintained in situ in the kidneys for 5 hr. Six hours after cardiac arrest, the kidneys were removed and preserved ex vivo at 4 degrees C for 24 hr, and were then transplanted into their respective hosts (n = 11), where they sustained life uneventfully. This method requires a 2-inch incision in the groin of the prospective donor, and two small stab wounds of the abdomen; i.e., semi-invasive procedures which are commonly performed in emergency rooms. The perfused body could then be released to the family if donation is denied. The recently documented increased willingness of the public to donate organs when the termination of life support is not an issue, and court decisions that have authorized the performance of nondeforming diagnostic procedures in cadavers without consent, suggest that the salvage of transplantable semi-invasive procedures described in this study may be useful in helping to alleviate the current shortage of transplantable organs. This technique can provide the time needed for families to consider the option of organ donation from nonheartbeating cadaver donors in an unhurried and unpressured manner, while preserving the viability of vital organs during the decision-making process.
Asunto(s)
Ética Médica , Trasplante de Riñón , Preservación de Órganos/métodos , Donantes de Tejidos , Obtención de Tejidos y Órganos , Experimentación Animal , Animales , Cadáver , Perros , Riñón/irrigación sanguínea , Perfusión , Choque Hemorrágico , Soluciones , Temperatura , Factores de TiempoRESUMEN
The role of humoral immune factors in graft destruction is not fully understood. With immunofluorescence techniques the possibility of a specific pattern and/or clustering of immune complex or complement deposits was analyzed in 140 percutaneous kidney needle biopsies performed in 73 patients with renal allograft dysfunction. The results were correlated with concomitant alterations in renal blood flow as measured by cortical and global perfusion indexes and graft survival. The deposition of IgG, IgM, C3 and C4 correlated significantly with acute rejection confirmed by biopsy (p less than 0.05, less than 0.001, less than 0.02 and less than 0.001, respectively). Subsequent graft survival was compromised when IgA, IgG, IgM, C3, C4 and properdin were present together in biopsy specimens (p less than 0.05). There was a significant clustering of IgA with C3, of IgG with C3 and C4, and of IgM with C1, C3 and C4 (p less than 0.001). There also was a significant association among alterations in renal blood flow, deposition of IgA (p less than 0.05) and C4 (p less than 0.02), and graft outcome. Higher perfusion indexes, indicative of decreased blood flow, showed significant associations (p less than 0.007 and less than 0.04 for the cortical and global perfusion indexes, respectively) with a greater risk of graft loss. Although it primarily is a cellular event, the data suggest that acute rejection is associated with a deposition of various humoral factors that may mediate alterations in renal blood flow. The latter may affect graft function and structural integrity, and, thus, may show a direct correlation with the outcome of a graft.
Asunto(s)
Complejo Antígeno-Anticuerpo/análisis , Proteínas del Sistema Complemento/análisis , Rechazo de Injerto/inmunología , Trasplante de Riñón/inmunología , Circulación Renal/inmunología , Biopsia con Aguja , Análisis Factorial , Técnica del Anticuerpo Fluorescente , Humanos , Riñón/patología , Análisis MultivarianteRESUMEN
This report describes the successful treatment in a transplant recipient of a case of MK originating from the native urinary tract. As demonstrated, MK may pursue unexpected patterns to which conventional therapeutic guidelines may not be applicable. The type of surgical intervention used must be dictated by the extent and location of the disease and its complications. Withdrawal of immunosuppressive medication was useful in improving the patient's prognosis.