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Control of Postbiopsy Renal Hemorrhage With Renal Artery Vasopressin Infusion
TRANSPLANTATION
adopted. The successful reduction of the complication rate probably reflects a combination of increased physician awareness and supervision. M. G. F. 8 references
M.
biopsy hemorrhage offers advantages over selective embolization: 1) loss of renal parenchyma apparently does not occur, which is important especially in patients with depressed renal function, 2) subselective catheter tip placement is not necessary and perhaps undesirable, and 3) inadvertent embolization of other areas of the kidney or even nonrenal sites is obviated. If renal bleeding cannot be controlled with vasoconstrictor infusion transcatheter embolization still is available. M. G. F. 2 figures, 13 references
Arch. Surg., 119: 681-685 (June) 1984
Clinical Evaluation of a New Rapid Heparin Assay Using the Dye Azure A
Management of Renovascular Problems During Aortic Operations 0. PERRY AND M. F. SILANE, Division of Vascular Surgery, Department of Surgery, Cornell University Medical College, New York, New York
A total of 60 patients with primary aortic disease (aortic stenosis or aneurysm) who required simultaneous aortic and renal artery operations was divided according to the indications for renal artery repair: group 1-renovascular hypertension (10 patients), group 2-kidney salvage (11 patients, all except 1 with renal polar length greater than 9 cm. and critical arterial stenosis or complete occlusion with delayed distal filling of the main renal artery), group 3-improvement of renal function (3 patients with severe renal artery stenosis) and group 4-renal artery involvement in the diseased aorta (36 patients). In group 1, 4 patients were cured of hypertension and 5 improved, permitting better medical control. In group 2 the kidneys of 9 patients were saved and 2 subsequently were lost because of occlusion of main and accessory arteries. In group 3, 2 patients improved and had normal creatinine levels, while 1 remained unchanged and subsequently had severe azotemia. Two patients died within 2 weeks after emergency surgery for a ruptured aneurysm and another after an operation for an infected false aneurysm. Repair of renal artery lesions at the time of aortic reconstruction increases the risk (5 per cent mortality in the present series) compared to an aortic or renal operation alone but simultaneous repair may be needed for technical reasons. M. G.F. 19 references
Control of Postbiopsy Renal Hemorrhage With Renal Artery Vasopressin Infusion D.
C. SMITH, G. M. GRAMES, W. R. HOLLAND AND N. J. MEIKLE, Section of Nephrology, Department of Internal Med-
icine and Department of Radiology, Loma Linda University Medical Center, Loma Linda, California Arch. Intern. Med., 144: 1468-1469 (July) 1984 A 19-year-old woman with chronic renal insufficiency underwent percutaneous renal biopsy concomitantly with renal arteriography. Renal hemorrhage was demonstrated 30 minutes later by repeat arteriography and accompanied by mild hypotension. Infusion of vasopressin at 0.2 units per minute for 30 minutes into the renal artery through an angiographic catheter controlled the persistent, severe hemorrhage quickly after renal biopsy. Immediately after the infusion there was no arteriographic extravasation of contrast material. Also noted was a decrease in arterial tree caliber and a decrease in renal length by 0.5 cm. It is assumed that the vascular changes were temporary based on experience with vasopressin in the control of bleeding in the gastrointestinal tract, where its effects have been shown to resolve in 10 to 15 minutes. The renal function did not deteriorate following the procedure. Vasopressin infusion into the renal artery for persistent post-
8. R. GUNDRY, M. D. KLEIN, R. A. DRONGOWSKI AND M. M. KIRSH, Sections of Pediatric Surgery and Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan Amer. J. Surg., 148: 191-194 (Aug.) 1984 To date, heparin assays are based on biological measures of activity. The simple whole blood clotting time, or the more complicated activated partial thromboplastin time or activated clotting time can be measured. Biological assays are timeconsuming, difficult to reproduce and require special devices. For this reason, assays for chemical heparin have been developed that use protamine or hexadrimethrine bromide as titrating agents, with coagulation of the specimen serving as the end point of titration. Despite the usefulness of these assays, all rely on the biological end point of coagulation to determine the amount of heparin within the blood. The authors have developed a colorimetric assay for chemical heparin in plasma based on the metachromasia of azure A in the presence of heparin. One ml. plasma is added to 1 ml. 0.08 per cent azure A, vortex mixed and read at 620 nm. in a spectrophotometer. To evaluate the clinical use of this assay the authors compared it to 2 biological assays of heparin effect, activated partial thromboplastin time and activated clotting time, and to heparin levels determined by protamine titration in 113 samples from 28 patients undergoing cardiopulmonary bypass. The azure A assay correlated well with the standard measures of heparin activity and heparin concentration. The azure A assay is more rapid, simple and less expensive than either of these tests, and does not depend on a bioassay coagulation as an end point. Chemical heparin measurements with azure A may be more useful clinically than the biological assays to determine the reversal dose of protamine. This assay may enable investigators to untangle the factors affecting the relationship of heparin amount to heparin effect. P. M. H. 3 figures, 11 references
TRANSPLANTATION Donor Ureteric Calculus Presenting as Acute Rejection in a Renal Transplant Recipient P.
K. DONNELLY, J. R. FARNDON AND R. R. ROY, Department of Surgery, University of Newcastle upon Tyne, Royal Victoria Infirmary, Newcastle upon Tyne, and Royal Infirmary, Sunderland, Tyne and Wear, Great Britain
Brit. Med. J., 288: 1961-1962 (June 30) 1984 A case is reported in which a ureteral calculus originating in a cadaveric donor kidney produced clinical signs of acute rejec-
adopted. The successful reduction of the complication rate probably reflects a combination of increased physician awareness and supervision. M. G. F. 8 references
M.
biopsy hemorrhage offers advantages over selective embolization: 1) loss of renal parenchyma apparently does not occur, which is important especially in patients with depressed renal function, 2) subselective catheter tip placement is not necessary and perhaps undesirable, and 3) inadvertent embolization of other areas of the kidney or even nonrenal sites is obviated. If renal bleeding cannot be controlled with vasoconstrictor infusion transcatheter embolization still is available. M. G. F. 2 figures, 13 references
Arch. Surg., 119: 681-685 (June) 1984
Clinical Evaluation of a New Rapid Heparin Assay Using the Dye Azure A
Management of Renovascular Problems During Aortic Operations 0. PERRY AND M. F. SILANE, Division of Vascular Surgery, Department of Surgery, Cornell University Medical College, New York, New York
A total of 60 patients with primary aortic disease (aortic stenosis or aneurysm) who required simultaneous aortic and renal artery operations was divided according to the indications for renal artery repair: group 1-renovascular hypertension (10 patients), group 2-kidney salvage (11 patients, all except 1 with renal polar length greater than 9 cm. and critical arterial stenosis or complete occlusion with delayed distal filling of the main renal artery), group 3-improvement of renal function (3 patients with severe renal artery stenosis) and group 4-renal artery involvement in the diseased aorta (36 patients). In group 1, 4 patients were cured of hypertension and 5 improved, permitting better medical control. In group 2 the kidneys of 9 patients were saved and 2 subsequently were lost because of occlusion of main and accessory arteries. In group 3, 2 patients improved and had normal creatinine levels, while 1 remained unchanged and subsequently had severe azotemia. Two patients died within 2 weeks after emergency surgery for a ruptured aneurysm and another after an operation for an infected false aneurysm. Repair of renal artery lesions at the time of aortic reconstruction increases the risk (5 per cent mortality in the present series) compared to an aortic or renal operation alone but simultaneous repair may be needed for technical reasons. M. G.F. 19 references
Control of Postbiopsy Renal Hemorrhage With Renal Artery Vasopressin Infusion D.
C. SMITH, G. M. GRAMES, W. R. HOLLAND AND N. J. MEIKLE, Section of Nephrology, Department of Internal Med-
icine and Department of Radiology, Loma Linda University Medical Center, Loma Linda, California Arch. Intern. Med., 144: 1468-1469 (July) 1984 A 19-year-old woman with chronic renal insufficiency underwent percutaneous renal biopsy concomitantly with renal arteriography. Renal hemorrhage was demonstrated 30 minutes later by repeat arteriography and accompanied by mild hypotension. Infusion of vasopressin at 0.2 units per minute for 30 minutes into the renal artery through an angiographic catheter controlled the persistent, severe hemorrhage quickly after renal biopsy. Immediately after the infusion there was no arteriographic extravasation of contrast material. Also noted was a decrease in arterial tree caliber and a decrease in renal length by 0.5 cm. It is assumed that the vascular changes were temporary based on experience with vasopressin in the control of bleeding in the gastrointestinal tract, where its effects have been shown to resolve in 10 to 15 minutes. The renal function did not deteriorate following the procedure. Vasopressin infusion into the renal artery for persistent post-
8. R. GUNDRY, M. D. KLEIN, R. A. DRONGOWSKI AND M. M. KIRSH, Sections of Pediatric Surgery and Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan Amer. J. Surg., 148: 191-194 (Aug.) 1984 To date, heparin assays are based on biological measures of activity. The simple whole blood clotting time, or the more complicated activated partial thromboplastin time or activated clotting time can be measured. Biological assays are timeconsuming, difficult to reproduce and require special devices. For this reason, assays for chemical heparin have been developed that use protamine or hexadrimethrine bromide as titrating agents, with coagulation of the specimen serving as the end point of titration. Despite the usefulness of these assays, all rely on the biological end point of coagulation to determine the amount of heparin within the blood. The authors have developed a colorimetric assay for chemical heparin in plasma based on the metachromasia of azure A in the presence of heparin. One ml. plasma is added to 1 ml. 0.08 per cent azure A, vortex mixed and read at 620 nm. in a spectrophotometer. To evaluate the clinical use of this assay the authors compared it to 2 biological assays of heparin effect, activated partial thromboplastin time and activated clotting time, and to heparin levels determined by protamine titration in 113 samples from 28 patients undergoing cardiopulmonary bypass. The azure A assay correlated well with the standard measures of heparin activity and heparin concentration. The azure A assay is more rapid, simple and less expensive than either of these tests, and does not depend on a bioassay coagulation as an end point. Chemical heparin measurements with azure A may be more useful clinically than the biological assays to determine the reversal dose of protamine. This assay may enable investigators to untangle the factors affecting the relationship of heparin amount to heparin effect. P. M. H. 3 figures, 11 references
TRANSPLANTATION Donor Ureteric Calculus Presenting as Acute Rejection in a Renal Transplant Recipient P.
K. DONNELLY, J. R. FARNDON AND R. R. ROY, Department of Surgery, University of Newcastle upon Tyne, Royal Victoria Infirmary, Newcastle upon Tyne, and Royal Infirmary, Sunderland, Tyne and Wear, Great Britain
Brit. Med. J., 288: 1961-1962 (June 30) 1984 A case is reported in which a ureteral calculus originating in a cadaveric donor kidney produced clinical signs of acute rejec-