Survival after surgical treatment for primary hyperparathyroidism

BACKGROUND: Reports have suggested that patients with primary hyperparathyroidism (pHPT) are at increased risk for premature death, even when they reach normocalcemia. This study addresses factors that may be of relevance for long-term outcome. METHODS: Between 1980 and 1984, 1052 patients (27% men and 73% women; median age, 59 years) underwent initial cervical exploration for pHPT. Long-term follow-up was obtained with regard to overall survival and cause of death. By using univariate and multivariate (Cox) survival analysis, subgroups of patients were compared. RESULTS: Median follow-up was 12 years (range, 0 to 15 years). Overall, survival was not decreased compared with the expected survival of a gender- and age-matched midwest population. Survival was better in patients with a history of kidney stones (p = 0.044), without osteoporosis (p = 0.004), and without muscle weakness (p = 0.013). CONCLUSIONS: Decreased long-term survival was not evident in this study. Age at the time of initial surgical treatment and the degree of endocrine activity of the diseased glands appear to be the most important independent prognostic factors for survival. Comparison of these data to prior Scandinavian data is not justified, principally because of the less advanced stage of disease in this study.     

Preoperative diagnostics and surgical management of tertiary hyperparathyroidism after chronic renal failure in a child

Although hyperparathyroidism if a rare condition in young children, the pediatric surgeon is asked occasionally to participate in the management of a child with parathyroid disease. In this paper we report on a girl with global glomerulosclerosis, an unsuccessful renal transplantation and a long-term peritoneal dialysis, who developed an autonomous hyperparathyroidism. Emphasis is placed on the preoperative diagnosis and surgical management in children.     

Herpes simplex esophagitis after renal transplantation

This paper describes five renal transplant recipients, out of a series of 221 consecutive patients, who developed herpes simplex esophagitis. This opportunistic infection presented as odyno- and/or dysphagia. It occurred during or shortly after treatment of acute cellular rejection episodes with high doses of steroids and, in four cases, of anti-lymphocyte globulins. The infection responded to acyclovir in all patients. We conclude from these observations that herpes esophagitis occurs during periods of intensive immunosuppression. Because its endoscopic manifestations are variable, biopsies and cultures are essential to reach the diagnosis. Prevention may be possible by avoiding transplantation from a seropositive donor to a negative recipient and by prophylactic oral acyclovir.     

De novo malignancy after renal transplantation

We reviewed the incidence of de novo malignancy in renal transplant recipients who received their grafts between 1979 and 1989, and had at least two years of graft function. Multiple attempts were made to contact 236 patients who were then surviving, or, in whom the medical history could be validated prior to death. There were 94 successful contacts, among whom 19 patients (20.12%) had developed 30 malignant lesions. There were 24 instances of skin and 6 of non-skin malignancy. Squamous cell carcinoma of the skin was the most common new malignancy observed.     

Guidelines for surgical procedures after liver transplantation

The ability to acquire a motor and cognitive skill was investigated in 26 patients with schizophrenia and 26 normal participants using repeated testing on the Tower of Toronto puzzle. Seven patients with defective performance were retested using additional trials and immediate feedback designed to facilitate problem solving. A component analysis of performance was used based on J. R. Anderson's (1987) model of cognitive skill learning. Patients exhibited a performance deficit on both motor and cognitive skills. However, their acquisition rate was similar to that of normal participants on most parameters, indicating that skill learning suffered little or no impairment. Performance deficit was accounted for by poor problem-solving ability, explicit memory, and general intellectual capacities. It was remediable in some, but not all, patients. Remediation failure was also related to severe defects of cognitive functions.     

Pregnancy after renal transplantation: 25 years experience in Spain

OBJECTIVES: To evaluate the kinetics of calcitriol (1,25(OH)2D3) administered subcutaneously. STUDY DESIGN: Calcitriol kinetics and efficacy after subcutaneous administration were studied in 13 CAPD patients with varying degrees of increased plasma levels of parathyroid hormone (i-PTH). A single dose of 2 micrograms of calcitriol was administered subcutaneously, and its serum levels at baseline and after 1, 2, 6, 12, and 24 hours were determined. Plasma ionized calcium and i-PTH were also determined at these periods. RESULTS: Serum calcitriol levels reached peak levels of 60 and 70 pg/mL at 1 and 2 hours after administration, respectively. These levels decreased thereafter, but remained above baseline values during 24 hours. The mean value of the area under the curve (AUC) was 809 +/- 226 pg/mL/hour. Plasma i-PTH levels showed a slight decrease after 1 and 2 hours, returning to baseline levels after this period. Plasma ionized calcium did not show significant changes during the study. A slight pain at the site of injection was mentioned by some patients. CONCLUSIONS: The subcutaneous route for calcitriol administration achieves theoretically adequate plasma levels in continuous ambulatory peritoneal dialysis (CAPD) patients. This is important when parenteral administration of calcitriol is considered in the treatment of secondary hyperparathyroidism.     

Hypertension two years after renal transplantation: causes and consequences

The incidence of hypertension 2 years after renal transplantation and the possible causes of hypertension were studied retrospectively. A group of 93 patients treated with cyclosporin (CyA), azathioprine (Aza), and/or prednisolone (Pred) were compared to a group of 31 patients treated with Aza and Pred. There were more patients with hypertension in the CyA group (73%) than in the Aza group (58%). Hypertension before transplantation predisposed to hypertension after transplantation. After transplantation, hypertension was most common among patients with polycystic kidney disease (46%), chronic glomerulonephritis (67%), and diabetes (71%). The accumulated immunosuppressive medication (CyA/Pred) did not affect the occurrence of hypertension. Hypertensive patients had significantly poorer graft function than did normotensive patients (serum creatinine level 229 mumol/l vs 162 mumol/l, P < 0.01). The 10-year graft survival was markedly impaired in the group with hypertension (42% vs 65% for normotensives, P < 0.05). The 10-year patient survival was 59% vs 79% (P = NS). The study further confirms the frequent finding that hypertension has a negative effect on graft and patient survival rates.     

Posterior urethral valves: long-term renal function consequences after transplantation

PURPOSE: We assessed the long-term efficacy of renal transplantation in children with posterior urethral valves. MATERIALS AND METHODS: We retrospectively compared the outcomes of renal transplantation in 66 children with posterior urethral valves and 116 with malformation uropathies (controls). RESULTS: Graft survival in the posterior urethral valves and control groups was 69 and 72% at 5 years, and 54 and 50% at 10 years, respectively (not statistically significant). A statistically significant increase in serum creatinine was noted at 10 years in children with posterior urethral valves but not in controls (p < 0.05). CONCLUSIONS: Renal transplantation in children with posterior urethral valves is not associated with a high rate of failure. However, long-term deterioration of graft function is likely related to lower urinary tract dysfunction.     

Determinants of graft survival after renal transplantation

We studied multiple determinants of graft survival at a single center and the effects of nonimmunologic graft loss on transplant survival. This retrospective study examined the results of 589 cadaver donor transplants performed between 1986 and 1992. Graft survival rates were calculated using Kaplan-Meier estimates for both overall graft survival (all causes of graft loss) and immunologic graft survival (function lost due to acute or chronic rejection and noncompliance). Cadaver graft survival was significantly poorer with an increasing degree of DR mismatch (P=0.02). An analysis of pretransplant variables showed graft loss risk was highest with greater DR mismatches, two B-antigen mismatch, higher donor serum creatinine, and younger recipient age. After transplantation, acute rejection was the most significant factor associated with long-term graft survival. Our data demonstrate a significant advantage for zero DR and one DR mismatch cadaver donor transplants, with excellent immunologic graft survival. This study suggests that a combination of immediate graft function, prevention of acute rejection by appropriate early immunosuppressive therapy, and acceptable DR match enhances cadaveric graft survival.     

Late complications after primarily successful renal transplantation

The occurrence of late renal and extrarenal complications of primarily successful kidney transplantations is surveyed. All cases in which some surgical or clinical complication, a rejection or complication of the treatment of rejection had occurred were omitted. Primarily, 46 out of 177 transplantations (26%) were completely successful. After six months, the continued course was entirely uneventful in 21 of these cases, while in 25 some kind of complication occurred 6-72 months after the primarily successful course, 19 renal in 17 patients and 23 extrarenal in 16. The complications could not be correlated to histocompatibility, sex, age or basic disease. It may be concluded that a favourable course during the first six months gives good hope of an uneventful continuation, although even serious complications may occur occasionally.