Effect of Pregnancy on Moderate Renal Failure in Reflux Nephropathy

DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY

Pre-Operative Identification of Patients at High Risk of Deep Venous Thrombosis After Elective Major Abdominal Surgery H. M. SUE-LING, D. JOHNSTON, M. J. McMAHON, P. R. PHILIPS AND J. A. DAVIES, University Departments of Medicine and Surgery, General Infirmary, Leeds, and Health Care Research Unit, University of Newcastle upon Tyne; Newcastle upon Tyne, United Kingdom

Lancet, 1: 1173-1176 (May 24) 1986 A study involving 128 patients 40 or more years old who underwent an elective abdominal operation was done to develop a predictive index for postoperative deep venous thrombosis. Postoperatively, deep venous thrombosis was detecteq. by a 125 iodine-fibrinogen scan. Two factors, patient age and euglobulin lysis time, correctly identified preoperatively 93 per cent of the patients in whom deep venous thrombosis developed and predicted incorrectly the development of deep venous thrombosis in only 17 per cent. In this study obesity and malignant tumors were not strong predictive factors. The use of this predictive index in general surgery patients could reduce the number of patients who receive routine prophylaxis against deep venous thrombosis by approximately 80 per cent. D. K. M. 2 figures, 3 tables, 26 references Prevention of Deep Venous Thrombosis and Pulmonary Embolism

National Institutes of Health, Bethesda, Maryland Lancet, 1: 1202-1203 (May 24) 1986 In the United States deep venous thrombosis and pulmonary embolism are estimated to be associated with 300,000 to 600,000 hospital admissions per year, and an estimated 50,000 deaths per year are believed to be owing to pulmonary embolism. In the United Kingdom deep venous thrombosis develops in 30 per cent of the pattents after abdominal or thoracic surgery and in 80 per cent after hip surgery. Pulmonary embolism causes approximately 15,000 deaths per year. Low dose heparin has been shown in randomized clinical trials to cause a 68 per cent decrease in deep venous thrombosis and a 49 per cent decrease in pulmonary embolism. The consensus development panel recommended prophylaxis for high risk patients. Specifically for urological patients, they recommend low dose heparin prophylaxis in those more than 40 years old. The use of external pneumatic compression requires more clinical trials in urological patients. D. K. M. Long-Term Blood Pressure and Renal Function in J{idney Donors

T.

TALSETH, P. FAUCHALD, S. SKREDE, 0. DJ0SELAND, K. J. BERG, J. STENSTR0M, A. HEILO, E. K. BRODWi\LL AND A. FLATMARK, Departments of Medicine, Clinical Chemistry,

Surgery and Radiology, Rikshospitalet, The National Hqspital, 0$lo, Norway Kidney Int., 29: 1072-1076 (May) 1986 Hyperperfusion and hyperfiltration of the remaining kidney in kidney donors have been considered to be a salutary adaptive phenomenon. The age-related progressive sclerosis of the rat kidney is accelerated after subtotal resection of a renal mass, suggesting a hemodynamically mediated injury to the rem'aining hyperperfused and hyperfiltering nephrons. It never has

981

been shown convincingly that unilateral nephrectomy in a healthy man can initiate a similar vicious circle of hyperperfusion injury to the remaining kidney. Nevertheless, the question has arisen as to whether the functional adaptation of the remaining kidney after kidney donation could be a detrimental process in time. The authors re-examined 68 of 74 donors (92 per cent) accepted at their center 9 to 15 years ago. There was a moderate but significant increase in blood pressure and 10 donors (15 per cent) had hypertension at the followup examination. Twentysix donors (38 per cent) had albumin excretion of more than 10 µg. per minute or excretion of total protein of more than 185 mg. per 24 hours. In 4 of the 16 donors with increased excretion of total protein this level exceeded 400 mg. per 24 hours and in 3 this could be owing to an intercurrent disease. Creatinine clearance averaged 78.4 per cent of the preoperative values and was less than 50 per cent (range 32 to 49 per cent) in 8 donors. The compensatory increase (median 30.5 ml. per minute per 1. 73 m. 2 ) was correlated inversely with age and b}ood pressure. Aspects of tubular function were assessed by the diluting capacity during water diuresis, and by urinary excretion of /Jrmicroglobulin and N-acetyl-f/-glucosaminidase. No consistent abnormalities were observed. A subgroup of 32 donors was compared to a matched control group. Urinary albumin excretion among the donors was significantly higher compared to the controls in absolute terms (5.4 versus 313 µg. per minute, p <0.002) and as a percentage of total protein excretion (7.6 versus 5.7 per cent, p <0.05). Otherwise, no consistent differences were observed. The development of increased blood pressure during time warrants further observations but there is p.o evidence that unilateral nephrectomy represents a long-term risk to donor health. W. W. H. 5 tables, 23 references Effect of Pregnancy on Moderate Renal Failure in Reflux Nephropathy

G. J. BECKER, B. U. IHLE, K. F. FAIRLEY, M. BASTOS AND P. KINCAID-SMITH, Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia Brit. Med. J.,

2V2: 796-798 (Mar. 22) 1986

The effect of pregnancy on renal disease is controversial. Some reports suggest that it is deleterious, especially if renal function already is impaired. Others have argued that the rapid decrease in renal function in some patients reflects the clinical course of the ~nderlying disease. The authors reported a high incidence of complications in pregnant women with reflux nephropathy. Since 1973 they studied prospectively patients presenting with reflux nephropathy to determine the features associated with a poor prognosis. During a 10-year study 20 women with reflux nephropathy had P,lasma creatinine concentrations of 0.2 to 0.4 mmol./1. (normal 2.3 to 4.5 mg./100 ml.). Six patients experienced pregnancies exceeding 12 weeks of gestation. Pregnancy was associated with rapid deterioration in function in all 6 patients, which resulted in end stage renal failure in 4 within 2 years after delivery despite adequate control of blood pressure. Of the 14 women who did not have a prolonged pregnancy 4 had periods of uncontrolled hypertension, all of which were related to noncompliance and/or loss to followup. Uncontrolled hypertension also was associated with accelerated renal failure and all 4 women had rapid progression to end stage renal disease. In the remainin~ 10 women, who were observed for 5 to 10

982

PREOPERATIVE AND POSTOPERATIVE THERAPY

years, renal function deteriorated slowly and none had end stage renal failure within 7 years. Pregnancy in patients with reflux nephropathy and moderately severe renal failure has a deleterious effect on renal function. W. W. H. 3 figures, 1 table, 28 references

TRAUMA Trauma Prophylaxi!'!: Every Physician's Responsibility P. lV(UCHA, JR.,

Department of Surgery, Mayo Clinic, Rochester,

Minnesota

Mayo Clin. Proc., 61: 3~8-391 (May) 1986 While many medical· advancements in the care of injured patients have occurred, there has been little attention to reducing the incidence of traumatic events that lead to serious injury. Indeed, many types of a~cidents are becoming more frequent. Physicia~s should assuµie a leadership role in actively supporting legislation and chllqges in social values that would result in fewer incidents of major trauma. Specifically, the author sqpports reduced speed liinits, enforcement of drunk driving laws, mandatory use of seat belts and motorcycle helmets, licensing for all-terrain vehicles, laws requiring mandatory incarceration for those convicted of a felony while armed and registration of hand guns. D. K. M. 6 references Genitourinary Injuries Secondary to Break Dancing in Children and Adolescents C. LOWE, Department of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Hos· pital, Baltimore, Maryland

J. P. GEARHART AND F.

Pediatrics, 77: 92Z~924 (June) 1986 Two cases of lower genitourinary tract injury secondary to break dancing are reported. An 8-year-old boy suffered pain and swelling in the scrotum following spinning on the buttocks. Evaluation revealed a traumatic hematocele but an intact testis. Treatment consisted of observation only and recovery was uneyentful. A 12-year-old boy fell and struck the perineum on the corner of a ~offee table carrying out "a double squat kick following a hand pivot". Blood was noted at the meatus as well as gross hematuria. Retrograde urethrography revealed a partial ruptµre of the bulbar urethra with extravasation of urine. Three weeks of cystostomy tube drainage of the bladder resulted in healing without stricture. H. McC. S. 1 figure, 10 references

PREOPERATIVE AND POSTOPERATIVE THERAPY Prophylaxis of Complications After Urological Abdominal Surgery by Substitution of Plasma Proteins H. W. BAUER AND E. SCHMIEDT, Department of Urology and Policlinic, University of Munich Medical School, Gro{3hadern Clinic, Mµnich, West Germany

J. Surg. Oncol., 31: 174-177 (Mar.) 1986 A prospective study on 94 patients undergoing a transabdom-

inal urological operation was done to evaluate the effect of postoperatively administered plasm;1 proteins. A total of 46 patients received 1,000 ml. of a commercially available preserved 5 per cent human serum protein solution within 48 hours postoperatively, while 48 received 1,000 ml. of physiological saline. The 2 groups were compared on the basis of clinical disorders, such as problems of wound healing, respiratory complications, antibiotic administration within the first 8 days postoperatively, changes in rectal temperature and total leukocyte count within the first 5 days postoperatively. In 22 patients who received humim serum protein blood samples were taken to determine the al-antitrypsin activity immediately after the operation, and before and after the administration of serum protein. Of the 46 patients receiving serum protein 6 had respiratory complications compared to 16 of 48 in the untreated group. The difference is significant. For other disorders the difference was not significant between the treated and untreated groups. Of the 22 patients in whom the al-antitrypsin activity was measured 4 showed significantly decreased levels, including 3 who had & respiratory complication in the form of bronchopneumonia. This study demonstrates the advantage of preserved human serum protein, especially with respect to its al-antitrypsin activity. The differences in respiratory complications in both groups were significant. F. T. A. 1 figure, 1 table, 21 references Efficacy of Polyglycolic Acid Mesh Sling in Keeping the Small Bowel in th.e Upper Abdomen After Abdo:Qtinal Surgery: A l2-Month Study in Baboons D. F. DEVEREUX, M. I. FELDMAN, T. K. MCINTOSH, M. D. PALTER, M. T. KAVANAH, P. J. DECKERS AND L. F. WILLIAMS, JR., Division of Surgery, Section of Surgical On-

cology, Boston University Medical Center, Boston, Massachusetts and UMDNJ-Rutgers Medical School, Academic Health Science Center, New Brunswick, New Jersey

J. Surg. Oncol., 31: 204-209 (Mar.) 1986 Radiation therapy often is required for residual, recurrent or adjuvant tumor treatment in patients with pelvic malignancies after pelvic exenterati9n. Because of a 5 to 15 per cent incidence of radiation-induced small bowel injury, surgeons have attempted to keep the small bowel in the upper abdomen by using the omentum as an apron, retroperitonealizing the pelvic floor or using the bladder dome sutured posteriorly to the sacrum. The a,uthors attempted to overcome this problem by using an absorbable mesh made of polyglycolic acid in the form of a sling to prevent the small bowel from descending into the pelvis. The sling was placed in 2 female baboons. Baboon cho~ was resumed immediately and the animals were followed for up to 12 months. At 3 and 6 months barium was instilled into the stomach through a nasogastric tube with the animal under ketamine anesthesia. Upright x-rays were taken to examine the position of the small bowel. The films demonstrated the small bowel well above the line drawn between the sacral promontory and the symphysis pubis. There was no evidence of small bowel obstruction or fistula in either animal. One baboon was sacrificed at 6 months and 1 at 12 months following placement of the sling, and the abdomens were opened. In the 6-month baboon there were filmy adhesions but no evidence of obstruction nor gross evidence of mesh, bowel discoloration, devascularization, fistulas or localized sepsis. In the 12-month animal there were no adhesions nor gross evidence of mesh. The small bowel was free floating in the abdominal cavity. The colon and