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Query: UMLS:C0243026 (sepsis)
 52,417 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The significant arterial complications of renal transplantation are hemorrhage, infarction, stenosis and aneurysm formation. Hemorrhage is often associated with sepsis and may be lifethreatening. Large infarcts may be secondary to multiple small vessels or intraoperative hypotension with inadequate perfusion of the organ. Nephrectomy is invariably indicated in these situations. Renal artery stenosis with resultant hypertension may occur secondary to stenosis at the anastomosis, atherosclerotic plaque formation or intimal fibrosis of the renal artery. Operative reconstruction if the anastomotic site may relieve hypertension is selected patients but places the transplanted kidney greatly at risk. Aneurysm formation is often mycotic and is associated with multiple operations and wound sepsis. The iliac artery may be ligated without loss of limb, while the resultant claudication may be relieved by a surgical bypass procedure.
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PMID:A twenty year survey of arterial complications of renal transplantation. 110 38

Despite great improvement in patient and graft survival, the long-term morbidity and mortality in renal transplant recipients are still significant. Cardiovascular disease accounts for much of the mortality in long-term survivors; screening before the transplant procedure and adequate control of hypertension should help improve patient survival. Many of the gastrointestinal complications are due to overimmunosuppression and sepsis. Adequate management must include withdrawal of all immunosuppressive medications in order to save the patient's life. Liver disease is usually of viral origin; patients with chronic active hepatitis or cirrhosis should remain on dialysis. Chronic rejection is the major cause of graft loss in long-term survivors; it is unresponsive to antirejection treatment and its progression may be mediated by nonimmunologic mechanisms. Correctable problems such as renal artery stenosis and ureteral obstruction should be ruled out before a late deterioration in graft function is disregarded as chronic rejection. Post-transplant diabetes, osteonecrosis, cataracts, and nephrotoxicity are directly related to the various immunosuppressive drugs currently used. The lowest dose compatible with graft acceptance should help reduce the incidence of these nonfatal but significant complications. Recurrence of disease is a common histologic finding in many transplant recipients but, except for a few diseases such as HUS, FSGS, and oxalosis, it usually does not lead to graft failure. Successful transplantation restores fertility in many uremic patients. Adequate counseling on contraception is imperative in order to avoid unwanted pregnancies and to delay parenthood for at least 1 year. Current immunosuppressive agents are not teratogenic, no dose adjustments are necessary, and an ill-advised decrease in medication may precipitate a rejection episode. Premature delivery is the major problem in these patients and can be avoided by maintaining adequate graft function and controlling hypertension and infections. It is evident from this review that most of the long-term morbidity and mortality seen in renal allograft recipients are due to overimmunosuppression with sepsis or to side effects of the individual drugs, steroids being a common denominator in almost all cases. New immunosuppressive protocols must aim not only to improve patient and graft survival but also to avoid the many complications that limit the full rehabilitation of these patients.
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PMID:Problems in the long-term renal allograft recipient. 226 90

Fifteen pediatric patients (ages 5-17 years) with renovascular hypertension (RVH) are reported. The diagnosis was made by arteriogram in all patients as the intravenous pyelogram was not helpful in this group. Five patients had a coarctation of the abdominal aorta. Four of these had associated renal artery stenosis. Renal artery stenosis alone was present in 14 patients, unilateral in 8, and bilateral in 6. Three of the former had a contralateral hypoplastic kidney. A nephrectomy was performed in 2 patients, both of whom continue to be hypertensive. Renal revascularization was performed in 13 patients; one of these died of sepsis. Eight are normotensive, 2 are improved (normotensive with diuretics), and 2 remain hypertensive. The follow-up is from 1 to 15 years.
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PMID:Renovascular hypertension in pediatric patients. 365 34

The experience of the Peter Bent Brigham Hospital with 217 renal allografts functioning for more than 5 years is reviewed. Patient and graft survival were similar after 5 years, with patient survival being 88 and 66% at 10 and 15 years, respectively, and graft survival 85 and 75% at the same time intervals. Actuarial graft survival at 15 years was higher than patient survival because death with a functioning graft was not considered to be graft failure. No differences in patients or graft survival were found between living related and cadaver donor allografts. There were 33 deaths (15.2%), occurring from 5 1/2 to 20 1/2 years post-transplantation. Chronic liver failure and sepsis were the most common causes of death. Thirty-two patients (14.7%) lost their grafts after 5 years, most commonly from chronic rejection. Another 33 patients (15.2%) had evidence of graft dysfunction secondary to chronic rejection, recurrent glomerulonephritis, ureteral obstruction, or renal artery stenosis. Chronic rejection was generally not responsive to alterations in immunosuppressive medication. Complications of varying severity were common affecting 204 (94%) of the patients. The most frequent were hypertension, cataracts, avascular necrosis, malignancy, urinary tract infection, and pneumonia. These data demonstrate that transplant-related mortality and morbidity continue to occur in recipients of long-term renal allografts. These patients require careful and continuing care in medical centers experienced in transplantation.
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PMID:Late mortality and morbidity in recipients of long-term renal allografts. 681 39

From october '76 to march '79 at the Clinica Chirurgica I of the University of Bologna 50 renal graft have been performed with living donor in 8 cases and with cadaver donor in 42. In the living donor group there was one death for rejection and sepsis. The remaining 7 patients are all alive with normal renal function. Among the 42 patients with cadaver donor 6 died: 3 early (one for gastric hemorrage, one for necrosis of the ascending colon, and one for rejection) and 3 late (two following many rejection episodes and one for miocardial infarction). 6 more patients underwent transplantectomy (4 for acute and 2 for chronic rejection). The 27 remaining patients have normal renal function. The only early important surgical problem was one urinary fistula in the 15th postoperative day successfully reoperated. The major late surgical complication was a renal artery stenosis distal from the arterial anastomosis followed by difficult but effective surgical correction. The authors regret not having been able to use more than half of the possible cadaver donors for refusal of the relatives.
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PMID:[Renal transplantation in Bologna]. 700 29

Vascular endothelium releases nitric oxide (NO), an important vasodilator that is continuously synthesised by the constitutive enzyme, endothelial nitric oxide synthase (NOS). This maintains a constant vasodilator tone which is diminished in adult hypertension, due to reduced endothelium-dependent vascular relaxation, which is NO dependent. In childhood, however, hypertension is often secondary, and normalisation of blood pressure by removal of cause (e.g. renal artery stenosis, catecholamine-producing tumour) suggests reversibility of endothelial dysfunction, if it is present. Raised plasma levels of endogenous inhibitors have been found, especially in children with secondary hypertension due to renal parenchymal and renovascular disease, and may contribute to hypertension by more than just inhibition of vascular NO release; e.g. by reduction of glomerular filtration rate and promotion of salt and water retention. These inhibitors also modulate renin release, which may be of relevance in cardiovascular physiology, and may also interfere with the anti-platelet properties of NO, increasing the likelihood of vascular thrombotic events. NO inhibitors also promote endothelial activation, with increased expression of adhesion molecules that may form seedlings of atherosclerosis. In chronic renal impairment, accumulation of NO inhibitors may contribute to hypertension. Efficient long-session dialysis helps better interdialysis control of blood pressure in these subjects, independent of salt and water removal, suggesting that removal of such vasoactive agents may be important for efficient blood pressure control. There are a few studies assessing NO generation in hypertensive children via plasma nitrite and nitrate, the NO end products, which suggest normal or increased production as opposed to a reduction, perhaps as a compensatory phenomenon. In the treatment of hypertension, nitroprusside and nitrates exert their actions via NO donation. Excessive production of NO (usually via inducible NOS) or excessive administration (nitrovasodilators) can be cytotoxic and may cause hypotension and shock, as in severe sepsis. NOS inhibitors and NO therefore appear to play a crucial role in aetiology, complications and therapy of childhood hypertension.
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PMID:Vascular endothelium and nitric oxide in childhood hypertension. 981 94

Intraoperative radiotherapy (IORT) permits the application of a single large radiation dose to a malignant mass at the time of surgery sparing adjacent normal tissue from irradiation. Since 1996 we have used IORT to treat 13 children with neuroblastoma, stage 3 - 4. In all cases the tumour was not radically resectable at the first operation. Ultrasound, CT and MRI were performed and patients were treated with chemotherapy according to the NB90 protocol. The second-look operation was performed in the IORT operating room where the tumour was resected as completely as possible, while keeping the "no risk" principle in mind. Localised radiation of the residual tumour was 8 - 10 Gy. The child was monitored via 3 video cameras. No technical problems occurred during IORT application. The follow-up time was 6 - 69 months (May 2001). One patient died due to tumour progression, another in complete remission died after 9 months due to sepsis. The clinical course of 2 patients was complicated by a renal artery stenosis and a mesenteric artery occlusion. All other patients are in complete remission with regular follow-up examinations. Although the results are promising the number of patients is too small as yet for statistical analysis. However, IORT can be safely applied in patients with high-risk neuroblastomas, reducing the dose, side effects and resulting in remission.
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PMID:IORT (intraoperative radiotherapy) in neuroblastoma: experience and first results. 1236 3

Numerous anatomical and functional changes occurring in the aging kidney lead to reduced glomerular filtration rate, lower renal blood flow and impaired renal autoregulation. The elderly are especially vulnerable to the development of renal dysfunction and in this population acute renal failure (ARF) is a common problem. ARF is often iatrogenic and multifactorial; common iatrogenic combinations include pre-existing renal dysfunction and exposure to nephrotoxins such as radiocontrast agents or aminoglycosides, use of NSAIDs in patients with congestive cardiac failure and use of ACE inhibitors and diuretics in patients with underlying atherosclerotic renal artery stenosis. The aetiology of ARF is classically grouped into three categories: prerenal, intrinsic and postrenal. Prerenal ARF is the second most common cause of ARF in the elderly, accounting for nearly one-third of all hospitalized cases. Common causes can be grouped into true volume depletion (e.g. decreased fluid intake), decreased effective blood volume (e.g. systemic vasodilation) and haemodynamic (e.g. renal artery stenosis, NSAID use). Acute tubular necrosis (ATN) is the most common cause of intrinsic ARF and is responsible for over 50% of ARF in hospitalized patients, and up to 76% of cases in patients in intensive care units. ATN usually occurs after an acute ischaemic or toxic event. The pathogenesis of ATN involves an interplay of processes that include endothelial injury, microvascular flow disruption, tubular hypoxia, dysfunction and apoptosis, tubular obstruction and trans-tubular back-leak. Vasculitis causing ARF should not be missed as this condition is potentially life threatening. The likelihood of a postrenal cause for ARF increases with age. Benign prostatic hypertrophy, prostatic carcinoma and pelvic malignancies are all important causes. Early identification of ARF secondary to obstruction with renal imaging is essential, and complete or partial renal recovery usually ensues following relief of the obstruction.A comprehensive medical and drug history and physical examination are all invaluable. Particular attention should be paid to the fluid status of the patient (skin turgor, jugular venous pressure, lying and standing blood pressure, urine output). Urinalysis should be performed to detect evidence of proteinuria and haematuria, which will aid diagnosis. Fractional excretion of sodium and urine osmolality may be measured but the widespread use of diuretics in the elderly gives rise to unreliable results. Renal imaging, usually ultrasound scanning, is routinely performed for assessment of renal size and to exclude urinary obstruction. In some cases, renal biopsy is necessary to provide specific diagnostic information. The general principles of managing ARF include treatment of life-threatening features such as shock, respiratory failure, hyperkalaemia, pulmonary oedema, metabolic acidosis and sepsis; stopping and avoiding administration of nephrotoxins; optimization of haemodynamic and fluid status; adjustment of drug dosage appropriate to glomerular filtration rate; early nutritional support; and early referral to nephrologists for diagnosis of ARF cause, timely initiation of dialysis and initiation of specific treatment. The treatment of prerenal and ATN ARF is largely supportive with little evidence of benefit from current pharmacological therapies. Despite advances in critical care medicine and renal replacement therapy, the mortality of ARF has not changed significantly over the last 40 years, with current mortality rates being up to 75%.
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PMID:Management of acute renal failure in the elderly patient: a clinician's guide. 1854 Jun 87