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Review of a large renal transplant experience revealed a 17.3% incidence of posttransplant erythrocytosis. The influence of kidney source, pretransplant hematocrit, duration of pretransplant dialysis, renal transplant function, acute rejection, transplant renal artery stenosis, urinary tract obstruction, smoking, diabetes, retention of native kidneys, splenectomy, parathyroidectomy, immunosuppression, hypertension, and liver enzyme abnormalities on the development of erythrocytosis in 53 recipients was determined. Comparison was made with 49 control recipients matched for kidney function, time after grafting, age, and sex. Erythrocytosis occurred 3 to 90 months after transplantation and persisted for 1 to over 84 months. Risk factors for the development of erythrocytosis were smoking, diabetes, and a rejection free course. In contradistinction to previous smaller series, erythrocytosis occurred in patients with good renal function (serum creatinine 1.62 +/- 0.43 mg/dl) without prominence of graft rejection, transplant artery stenosis or obstruction. Despite therapeutic phlebotomy, 11 thromboembolic events occurred in 10 of the 53 patients with erythrocytosis, but in none of the controls (P less than 0.001). The high incidence of erythrocytosis following renal transplantation and the risk of associated thromboembolic events should encourage awareness and controlled evaluation of therapeutic modalities.
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PMID:Postrenal transplant erythrocytosis: a review of 53 patients. 634 69

Persons with either borderline or established hypertension should always be instructed in a series of general measures. These include a reduction of overweight, dietary salt restriction, no smoking, whenever possible discontinuation of oral contraceptives, appropriate physical exercise, and treatment, primarily by diet, of a coexisting hyperlipidemia. Such non-pharmacologic measures may often improve the potential risk constellation and in some persons with borderline or mild hypertension even normalize the blood pressure. Pharmacotherapy is recommended only in selected cases with persistent borderline blood pressure elevation but, on a partly empirical basis, appears usually to be indicated for established hypertension of greater than or equal to 160/95 mm Hg. The coexistence of diabetes mellitus or renal functional impairment and advancing age of a patient deserve special consideration in the choice and/or dosage of antihypertensive drugs. Failure to achieve satisfactory blood pressure control through general measures and appropriately dosed triple drug therapy (including a diuretic, a betablocker or other sympatholytic or calcium antagonist, and (di)hydralazine, prazosin or endralazine) calls for thorough reevaluation of the situation. Causes which may simulate or induce resistant hypertension include technical problems with measurement, oral contraceptives, insufficient patient cooperation, sodium fluid volume retention, insufficient pharmacotherapy, drug interactions, "office hypertension" with satisfactory blood pressure in the patient's daily environment, and potentially operable causes such as renal artery stenosis or pheochromocytoma. If none of these factors is present, persistent uncontrolled hypertension can very often be treated satisfactorily with newer potent drugs such as the convertase inhibitor captopril as first choice agent in women, or the direct vasodilator minoxidil as the preferred agent in men. Together with the necessary steps to improve patient compliance, including increased blood pressure measurements by the patient himself, practitioners can now rely upon effective therapeutic tools. The present social and economic burden resulting for the individual and the public from neglected therapeutic opportunities, from excess morbidity and early death due to inadequately treated hypertension, can and must be reduced in the interests of the community at large.
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PMID:[Long-term treatment of hypertension in 1983]. 641 60

Diabetes mellitus is a common multisystemic disease with serious effects on the genitourinary system. In the radiology literature, little attention has been paid to developing an integral approach to imaging of the genitourinary tract in diabetes. The long-term effects of diabetes on the genitourinary system include diabetic nephropathy, papillary necrosis, renal artery stenosis, diabetic cystopathy, and vas deferens calcification. Diabetes-associated urinary tract infections include renal and perirenal abscesses, gas-forming infections such as emphysematous pyelonephritis and emphysematous cystitis, fungal infections, and xanthogranulomatous pyelonephritis. Diabetes-associated genital infections include Fournier gangrene and postmenopausal tubo-ovarian abscess. In a diabetic with fever of unknown origin or in the event of a persistent infection in a diabetic with clinical deterioration despite use of antibiotics, radiologic studies can demonstrate the presence of genitourinary complications. Finally, radiologists should be aware of the risk of contrast material-induced nephropathy in diabetics.
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PMID:Imaging the effects of diabetes on the genitourinary system. 750 50

The role of nephron-sparing surgery for renal cell carcinoma is well established in patients with an anatomical or functional solitary kidney (imperative indication) in which a radical nephrectomy would render the patient anephric with subsequent need for hemodialysis. This also encompasses patients with a unilateral renal cell carcinoma and a functioning contralateral kidney when the opposite renal unit is affected by a disease that might threaten its future function, such as renal artery stenosis, chronic pyelonephritis, stone disease or systemic conditions such as diabetes. A functioning renal remant of at least 20% of normal renal parenchyma seems to be necessary to avoid end-stage renal failure in these patients [16]. There have been several reports in the literature of excellent 5-year cancer-specific survival rates of over 80% in such circumstances [12, 15]. These results were confirmed in our institution, with a 5-year cancer-specific survival rate of 83% in over 70 patients with an imperative indication for nephron-sparing surgery. Thereby the prognosis was significantly influenced by the local tumor stage and the grade of malignancy. These data support the efficacy of nephron-sparing surgery in this clinical situation.
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PMID:Current controversies in nephron-sparing surgery for renal-cell carcinoma. 755 Mar 88

This study sought to characterize patients with renal papillary necrosis seen at one tertiary referral center by reviewing medical records of patients with a confirmed diagnosis between January 1, 1976 and September 1, 1992. One hundred sixty-five cases were identified. The mean age at diagnosis was 57 yr (SD 15). The female-to-male ratio was 1.1:1.0. Ninety-two percent of patients were white. Seventy-seven percent of cases were unsuspected before diagnosis, and 16% were diagnosed at autopsy. The most common associated conditions were urinary tract infection, analgesic abuse, urinary tract obstruction, diabetes mellitus, and sickle cell disease. There was considerable overlap in the presence of these conditions, with two or more identified in 36% of patients. In addition, 11% of patients had none of these well-recognized risks. Other diagnoses in this group included lupus nephritis, Wegener's granulomatosis, and renal artery stenosis. A decline in case numbers of approximately 50% was demonstrated over the last 10 yr studied. This period was associated with a 57% reduction in the number of excretory urograms carried out, suggesting that changes in diagnostic imaging preference may have contributed. Vital status and renal outcome data after diagnosis were obtained in 93% of cases. Of those diagnosed while living, survival was lowest among diabetic patients. Ten-year survival for nondiabetics was not significantly different from the expected survival of an age- and sex-matched cohort. The overall risk for requiring renal replacement therapy after the diagnosis of renal papillary necrosis in surviving patients was low (7% of 136 patients at risk).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Renal papillary necrosis--a sixteen-year clinical experience. 757 92

Angiotensin-converting enzyme (ACE) inhibitors represent a major therapeutic breakthrough for treatment of hypertension, congestive heart failure and various chronic renal diseases. They are effective generally well tolerated and safe for most patients. However, acute renal insufficiency or overt renal failure occurs in some patients with underlying critical renal artery stenosis (RAS), hypertensive nephrosclerosis, autosomal dominant polycystic kidney disease, diabetes mellitus, and chronic congestive heart failure. Diuretic-induced sodium depletion and underlying chronic renal insufficiency are the major predisposing factors for renal insufficiency in all of these patient populations. Renal insufficiency is usually asymptomatic, nonoliguric, associated with hyperkalemia, and in nearly every case completely reversible after discontinuation of the offending agent. Moreover, it can usually be managed in the outpatient setting by discontinuation of the ACE inhibitor, concomitant diuretic or both. An asymptomatic increase in serum creatinine in patients administered ACE inhibitors should raise the possibility of RAS; however, more common renal diseases should be considered. The decision to pursue testing for RAS should be done on an individual basis; moreover, it is imperative that patient willingness to undergo invasive procedures including angioplasty and/or surgery should be determined prospectively.
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PMID:Renal insufficiency due to angiotensin-converting enzyme inhibitors. 784 22

Renal angiography remains the "gold standard" procedure for the detection of renal artery stenosis. However, clinicians often avoid renal angiography because of fears of contrast media-associated nephrotoxicity (CM-AN) and atheroembolism. This review focuses on these potential angiographic complications, with particular emphasis, in the case of CM-AN, on clinical features, incidence, risk factors with an emphasis on pre-existing renal insufficiency and diabetes mellitus, volume of contrast media, low osmolar versus high osmolar contrast media, and prophylaxis. For atheroembolism, areas emphasized are pathology, clinical features, precipitating features, and incidence in various settings. Although the literature contains an abundance of information about CM-AN and atheroembolism, this review identified multiple areas of uncertainty regarding features of both of these complications. For example, additional studies are needed to determine the incidence of CM-AN, both asymptomatic and clinically severe, in patients with a wide range of pre-existing renal insufficiency with and without diabetes mellitus, following low volume digital subtraction renal angiography with low osmolar contrast media. In a similar manner, studies are needed with adequate postcontrast observation periods to determine the true incidence of clinically significant atheroembolism following diagnostic renal angiography and angioplasty and techniques that may modify this complication. Until further knowledge in both of these areas is available, it is difficult to precisely determine the risks of renal angiography and/or angioplasty in the azotemic patient suspected of or having renal ischemic disease using modern radiologic techniques.
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PMID:Nephrotoxic risks of renal angiography: contrast media-associated nephrotoxicity and atheroembolism--a critical review. 794 32

The incidence of renal artery stenosis (RAS) in patients with coronary artery disease (CAD) has not been well documented. Over a 9-month period, 196 patients who underwent coronary angiography because of clinically suspected CAD had routine nonselective renal cine or digital subtraction angiography. There were 68 females and 128 males with a mean age of 63 years (range 35-85). Angiographically significant CAD was present in 152 patients (78%). Of the total patient cohort, 29 patients (15%) had mild RAS (< 50%), and 36 patients (18%) had significant RAS (> or = 50%). In patients with normal coronary arteries, only three patients (7%) had RAS. Thirty-three patients (92%) with severe RAS also had CAD. Of these 33 patients, 45% had hypertension, 30% had hyperlipidemia, 24% had diabetes mellitus, 24% had renal insufficiency (creatinine > or = 1.5), and 51% were smokers. In addition, it was noted that 20 of these patients (61%) had two or more of the above-listed clinical parameters. However, univariate analysis using the chi-square test revealed that only CAD (22% P < 0.03) and renal insufficiency (29% P < 0.15) were reliable clinical predictors of RAS. In conclusion, RAS is a frequent finding in patients with CAD, particularly when renal insufficiency is also present.
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PMID:High incidence of renal artery stenosis in patients with coronary artery disease. 803 26

In idiopathic thrombocytopenic purpura, a known immune-mediated disorder, intravenous IgG is the treatment of choice. Success and the lack of side effects of intravenous IgG in the treatment of idiopathic thrombocytopenic purpura have encouraged consideration of its use in the treatment of neurologic disorders of presumed autoimmune pathogenesis. In this report, we describe two patients who developed acute renal failure following intravenous IgG treatment. The first patient had chronic inflammatory demyelinating polyneuropathy and was treated with intravenous IgG instead of prednisone because of preexisting diabetes. The second patient had idiopathic thrombocytopenic purpura and received intravenous IgG treatment as part of standard care. The patient with idiopathic thrombocytopenic purpura had unrelated bilateral high-grade renal artery stenosis. Both patients had a creatinine level of 140 mumol/L (1.6 mg/dL) prior to treatment. Renal biopsies performed during acute renal failure in each patient demonstrated marked swelling and vacuolization of the proximal tubular epithelial cytoplasm typical of high-solute-load-induced damage (similar to that associated with the use of mannitol). This report draws attention to the importance of screening for impaired renal function before intravenous IgG therapy is initiated. The patients we describe received standard doses of intravenous IgG at the recommended infusion rate yet developed oliguric renal failure. Awareness of serious side effects and recognition of predisposing factors provide means of avoiding known life-threatening complications of intravenous IgG therapy.
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PMID:Acute renal failure resulting from intravenous immunoglobulin therapy. 843 Nov 31

Platelet volume is a marker of platelet function and activation. It is readily measured as mean platelet volume (MPV) by clinical haematology analysers using sodium citrate as the anticoagulant. Measurement in EDTA can be unreliable since MPV increases significantly in a time-dependent manner. MPV correlates with platelet function and activation, whether measured as aggregation, thromboxane synthesis, beta-thromboglobulin release, procoagulant function, or adhesion molecule expression. MPV is increased in certain vascular risk factor states, including hypercholesterolaemia and diabetes mellitus, but not essential hypertension. It is increased in acute myocardial infarction, acute ischaemic stroke, pre-eclampsia and renal artery stenosis. Importantly, an elevated MPV predicts a poor outcome following myocardial infarction, restenosis following coronary angioplasty, and the development of pre-eclampsia. Research into the epidemiology of MPV is now required to determine whether thrombomegaly is a risk factor for developing vascular disease. Similarly, the physiological mechanisms which regulate MPV within the megakaryocyte need to be elucidated. Whether MPV ever becomes a routinely requested test remains to be seen but changes in methodology will be required first.
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PMID:Platelet size: measurement, physiology and vascular disease. 873 7


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