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Nonb Hepatitis During Coagulation Pyelolithotomy
0022-5347//89/1414~0923$2.00/0 THE JOUfiNAL OF UROLOGY Copyright© 1989 by The Williams & 'Nilkins Co.
TRANSM ISSION OF NONA/NO NB HEPATIT IS DURING COAGULATION PYELOLI THOTOM Y KEVIN T. McVARY AND VINCENT J. O'CONOR* From the Department of Urology, Northwestern University Medical School, Chicago, Illinois
ABSTRACT
The use of coagulum for renal stone surgery is an important yet less frequently used tool in the urological armamentarium . We report the first documented case of transmission of viral hepatitis during coagulum pyelolithotomy . We review the basic tenets of its use, with a brief discussion of the blood-borne transmission of viral particles and risk of hepatic injury with volatile anesthetic agents, and propose the continued safe use of coagulum by autologous donation of cryoprecipitate . (J. Ural., 141: 923-925, 1989) The use of coagulum pyelolithotomy was first described by Dees in 1943 using human fibrinogen and clotting globulin as the major components of the coagulum. 1 Since then many refinements have been added to the procedure. Its use as treatment for renal calculi has been restricted with the advent of percutaneous nephrolithotomy and, more recently, extracorporeal shock wave lithotripsy. Recently, we used this technique under special circumstances and report the first known case of hepatitis transmission secondary to the use of intrapelvic cryoprecipitate and its systemic absorption. CASE REPORT
After waiting 10 minutes a pyelotomy incision was made near the site of the proposed dismembered pyeloplasty and the coagulum containing the multiple stones was teased from the renal pelvis in a form consistent with the entire collecting system (fig. 3). Intraoperative kidney radiographs ensured that all stones were removed. Films of the coagulum stone mass revealed the presence of all suspected stones. At this time the ureteropelvic junction obstruction was repaired using the dismembered technique. Operative blood loss was estimated at 400 cc and no intravenous transfusions were used. The patient was discharged from the hospital on postoperative day 7. Crystallographic examination of the urinary calculi (weighing 5.4 gm.) revealed calcium oxalate. Three weeks after the patient was discharged from the hospital he presented to the office complaining of nausea, fatigue, occasional diarrhea and milk colored stools. Physical examination was remarkable for scleral icterius and a tender right upper quadrant. Ultrasound of the biliary tract confirmed absence of the previously removed gallbladder, no common bile duct dilatation, no enlargement of the pancreas and no biliary stones. Pertinent laboratory studies included lactate dehydrogenase 735 (normal 0 to 250), alkaline phosphatase 283 (normal 30 to 115), serum glutamic oxaloacetic transaminase 2,770 (normal 0 to 30) and total bilirubin 6.6 (normal 0 to 1.2). Hepatitis B surface antibody, hepatitis B core antibody, hepatitis B e antigen and hepatitis A antigen were all negative. During the next 8 weeks the liver function tests, serum bilirubin and general well being approached baseline. Reviewing the 10 donated cryoprecipitate units confirmed that were negative for human immunodeficiency virus, hepatitis B antigen and rapid plasma reagent. However, these units were not sc1·eened for the presence of elevated serum glutamate pyruvate transaminase, a presumed indicator of nonA/nonB hepatitis, nor hepatitis B core antibody. Our opinion is that the nonA/nonB hepatitis was a result of the use of the human cryoprecipitate during the coagulum pyelolithotomy despite the fact that there was no intravenous blood transfusion. We presume that there was systemic absorption of blood products injected into the renal pelvis via the periforniceal venous system.
A. M., a previously healthy 53-year-old man, presented with recent onset of asymptomatic total gross hematuria. The patient had no history of urinary complaints. Medical history was remarkable only for cholecystectomy 8 years previously. Urinalysis revealed more than 100 red blood cells per high power field, no bacteria and 5 to 6 white blood cells per high power field. Urine culture was unrewarding while cystoscopy showed blood coming from the left ureteral orifice. An excretory urogram (IVP) showed multiple calculi in the left renal pelvis and the upper major calix (fig. 1), prompt excretion of contrast medium bilaterally, and marked dilatation of the left renal pelvis and collecting system with obstruction at the ureteropelvic junction (fig. 2). The screening chemistry studies were unremarkable, including normal liver function studies and nonreactive reagin circle card test (rapid plasma reagent). It was decided to repair the ureteropelvic junction obstruction while removing the large stone burden with the aid of coagulum pyelolithotomy. A subcostal incision was used to gain access to the left inferior renal pole with the patient under nitrous oxide/ enflurane inhalation anesthesia. The dilated renal pelvis appeared to be secondary to a fibrous band crossing at the ureteropelvic junction. Approaching the pelvis posteriorly, an angiocatheter needle was placed into the pelvis and approximately 110 cc clear, yellow colored fluid were removed. After a soft silicone sling was secured just distal to the ureteropelvic junction (for purposes of preventing antegrade flow of coagulum) a mixture of thrombin, calcium chloride and 100 cc body temperature cryoprecipitate (drawn from a pool of 10 human cryoprecipitate units) was injected through the previously placed angiocatheter with strict attention to infusion DISCUSSION pressure. Infusion pressure was hand controlled by the operators avoiding excessive pressure during infusion. However, no The use of coagulum precipitate was described first by Dees in-line manometer was used during the cryoprecipitate infusion in 1943. 1 Because of its technical complexity, the use of pooled to monitor infusion pressure. human fibrinogen and a significant risk of hepatitis transmission above that of a standard blood transfusion, it was a procedure not widely used. During the next 30 years several Accepted for publication October 2, 1988. *Requests for reprints: Department of Urology, Northwestern Uniinvestigators made valuable alterations, including the use of versity Medical School, 303 East Chicago Ave., Chicago, Illinois 60611. cryoprecipitate, which was more widely available, more uniform 923
,.....--
924
--
MCVARY AND O'CONOR
FIG. 1. A, abdominal radiograph reveals multiple calculi in area of left renal pelvis and upper calix. B, tomographic cut shows large starshaped calculus in renal pelvis and multiple smaller stones in upper and lower calices.
FIG. 2. IVP shows dilated left renal pelvis and hydronephrosis consistent with ureteropelvic junction obstruction.
FIG. 3. Coagulum in shape of collecting system after having been teased from left renal pelvis.
and of reproducible strength. 2 - 6 Other major improvement s include the use of thrombin, calcium chloride and intraoperative kidney radiographs in the search for occult stones, and the screening of all blood donors for hepatitis B. 7 • 8 Cryoprecipitate is prepared by thawing a unit of fresh frozen plasma at 4C and recovering the cold-precipitate protein by
centrifugation; Cryoprecipitate is obtained as a by-product of modern standard blood component therapy and constitutes the cold precipitatable proteins, primarily fibrinogen and factor VIII. The advantages of cryoprecipitate are its ready availability in any blood bank and the economy of using an otherwise wasted resource. Additionally, the incidence of hepatitis after use of nonpooled plasma products always is less than after use of pooled preparations. 9 • 10 Before routine hepatitis B screening the disease most frequently transmitted by blood transfusion was type B viral hepatitis. It is not easy to determine the incidence of this complication because of the nonicteric forms of the disease but the incidence is lower when blood donor selection excludes high risk hepatitis carriers, drug addicts and professional donors. Reported incidence of post-transfus ion hepatitis B is 0.3 to 9 cases per 1,000 transfused units, or 0.5 to 13 cases per 100 patients transfused. The risk increases linearly with the number of units of blood transfused. More of a problem is that of nonA/nonB post-transfus ion hepatitis, which accounts for 90 per cent of the cases following transfusion of voluntarily donated blood. 11 The incubation period of hepatitis may range from 45 to 160 days, while that of nonA/nonB ranges from 15 to 160 days. Recently, the Food and Drug Administrati on has suggested that all donors be screened for elevated serum glutamic pyruvic transaminase as a possible indicator of nonA/ nonB hepatitis. Additionally, new recommenda tions from the Food and Drug Administrati on advise screening all blood donors for hepatitis B core antibody to avoid any donors who have a history of hepatitis. 12 The possibility of an anesthetic-in duced hepatitis must be considered in any postoperative patient because development of some degree of hepatic necrosis after administratio n of volatile agents has been suspected. Large retrospective studies have indicated only a small chance that halothane in combination with genetic background, exposure to drugs, reduced hepatic flow or hypoxia might lead to some liver damage. 13 Our patient received enflurane, which is not an agent associated with liver dysfunction. 14 Less likely infectious agents responsible for the hepatitis in our patient include syphilis, Epstein-Barr virus and cytomegalovirus. The patient was screened for syphilis (nonreactive rapid plasma reagent) as were all blood products used. Cytomegalovirus is an isolated rare cause of hepatitis in the nonimmunocompromised patient. Thus, it is unlikely to be the underlying cause. Epstein-Barr virus is a rare cause of clinical hepatitis with several clinical hallmarks not found in our patient (sore throat, pharangeal inflammation , tender lymphadenopathy and short clinical prodrone). Jaundice is a rare complication of the Epstein-Barr virus (less than 3 per cent) and when it occurs it is accompanied by mild elevations of liver function tests (unlike our patient). More obvious in our patient was the lack of increased white blood cells, lymphocytes and atypical lymphocytes (both absolute and relative number). 15 Coagulum pyelolithotomy has been considered a reasonably safe operation for properly selected patients. However, Pence and associates described a patient undergoing pyelolithotomy who suffered a fatal pulmonary embolus during the procedure. 16 It was hypothesized that the thrombin injected into the renal pelvis was absorbed via the periforniceal venous system and led to the fatal event. They also described an animal model correlating the volume of coagulum above that necessary for filling the pelvis and concentration of thrombin with the incidence of detectable systemic absorption. Bhagavan and associates demonstrated that pyelovenous backflow occurs with an injection pressure above 30 mm. Hg and, therefore, by keeping injection pressure low one might avoid any systemic absorption.17 By using sterile in-line pressure transducers one would be able to control infusion pressure more accurately. In recent years the use of coagulum pyelolithotomy has decreased largely because of percutaneous nephrolithoto my and
TRANSMISSION OF NONA/NONB HEPATITIS DURING COAGULATION PYELOLITHOTOMY
extracorporeal shock wave lithotripsy. Its use will continue to have a role in the urological armamentarium but only under special circumstances, such as that outlined previously. The possibility of hepatitis transmission with this technique is a reality but it can be overcome with the use of autologous cryoprecipitate. One unit of whole blood can yield 10 to 20 cc precipitated proteins. This blood donation technique is available but requires the patient to donate approximately 1 week before the scheduled operation. 9 To produce the 100 cc autologous cryoprecipitate our patient would have been required to donate 5 to 10 units of blood preoperatively. Hopefully, most coagulum pyelolithotomies will not demand such quantities. Obviously, cases when large volumes of cryoprecipitate are needed may require the patient to accept some donor units. However, cryoprecipitate units, once donated, may be kept for extended periods and allow for large numbers of units to be used autologously. In summary, we report a case of nonA/nonB hepatitis subsequent to the use of intrarenal cryoprecipitate. Post-transfusion hepatitis epidemiology is reviewed briefly. We advise the use of autologous cryoprecipitate donation for any elective coagulum pyelolithotomy. REFERENCES 1. Dees, J. E.: The use of an intrapelvic coagulum in pyelolithotomy:
a preliminary report. South. Med. J., 49: 503, 1943. 2. Patel, V. J.: The coagulum pyelolithotomy. Brit. J. Surg., 60: 230, 1973. 3. Marshall, S.: Commercial fibrinogen, autogenous plasma, whole blood and cryoprecipitate for coagulum pyelolithotomy: a comparative study. J. Urol., 119: 310, 1978. 4. Broecker, B. H. and Hackler, R. H.: Simplified coagulum pyelolithotomy using cryoprecipitate. Urology, 14: 143, 1979. 5. Fischer, C. P., Sonda, L. P. and Diokno, A. C.: Use of cryoprecipi-
925
tate in extracting renal calculi. Urology, 15: 6, 1980. 6. Marshall, S.: Coagulum pyelolithotomy. Urol. Clin. N. Amer., 10: 659, 1983. 7. Beck, A. D.: Intraoperative radiography in conservative surgery for renal calculi. J. Urol., 110: 494, 1973. 8. Boyce, W. H.: The localization of intrarenal calculi during surgery. J. Urol., 118: 152, 1977. 9. Borucki, D. T.: Blood Component Therapy: A Physician's Handbook, 3rd ed. Washington, D. C.: American Association of Blood Banks, 1982. 10. Harrison, R. C.: Blood component therapy. In: Introduction to Anesthesia: The Principles of Safe Practice, 6th ed. Edited by R. D. Dripps, J. E. Eckenhoff and L. D. Vandam. Philadelphia: W. B. Saunders Co., chapt. 23, pp. 270-282, 1982. 11. Dienstay, J. L., Nanda, J. R. and Koff, R. S.: Acute hepatitis. In: Harrison's Principles of Internal Medicine, 9th ed. Edited by K. J. Isselbacher, R. D. Adams, E. Braunwald, R. G Peterdorf and J.D. Wilson. New York: McGraw Hill Book Co., part 5, sect. 6, pp. 1459-1470, 1980. 12. Memorandum: American Association of Blood Banks, Arlington, Virginia, May 27, 1987. 13. Badden, J. M. and Rice, S. A.: Metabolism and toxicity of inhaled anesthetics. In: Anesthesia, 2nd ed. Edited by R. D. Miller. New York: Churchill Livingstone, vol. 1, chapt. 22, p. 716-726, 1986. 14. Lewis, J. H., Zimmerman, H. J., Ishak, K. G. and Mullick, F. G.: Enflurane hepatotoxicity. A clinicopathologic study of 24 cases. Ann. Intern. Med., 98: 984, 1983. 15. Niederman, J. C.: Infectious mononucleosis. In: Infectious Diseases: A Modern Treatise of Infectious Processes, 3rd ed. Edited by P. D. Hoeprich. Philadelphia: Harper & Row Publishers, chapt. 137,pp. 1205-1211,1983. 16. Pence, J. R., II, Airhart, R. A., Novicki, D. E., Williams, J. R. and Ehler, W. J.: Pulmonary emboli associated with coagulum pyelolithotomy. J. Urol., 127: 572, 1982. 17. Bhagavan, B. S., Wenk, R. E. and Dutta, D.: Pathways of urinary backflow in obstructive uropathy: demonstration by pigmented gelatin and Tamm-Horsfall uromucoprotein markers. Hum. Path., 10: 669, 1979.
TRANSM ISSION OF NONA/NO NB HEPATIT IS DURING COAGULATION PYELOLI THOTOM Y KEVIN T. McVARY AND VINCENT J. O'CONOR* From the Department of Urology, Northwestern University Medical School, Chicago, Illinois
ABSTRACT
The use of coagulum for renal stone surgery is an important yet less frequently used tool in the urological armamentarium . We report the first documented case of transmission of viral hepatitis during coagulum pyelolithotomy . We review the basic tenets of its use, with a brief discussion of the blood-borne transmission of viral particles and risk of hepatic injury with volatile anesthetic agents, and propose the continued safe use of coagulum by autologous donation of cryoprecipitate . (J. Ural., 141: 923-925, 1989) The use of coagulum pyelolithotomy was first described by Dees in 1943 using human fibrinogen and clotting globulin as the major components of the coagulum. 1 Since then many refinements have been added to the procedure. Its use as treatment for renal calculi has been restricted with the advent of percutaneous nephrolithotomy and, more recently, extracorporeal shock wave lithotripsy. Recently, we used this technique under special circumstances and report the first known case of hepatitis transmission secondary to the use of intrapelvic cryoprecipitate and its systemic absorption. CASE REPORT
After waiting 10 minutes a pyelotomy incision was made near the site of the proposed dismembered pyeloplasty and the coagulum containing the multiple stones was teased from the renal pelvis in a form consistent with the entire collecting system (fig. 3). Intraoperative kidney radiographs ensured that all stones were removed. Films of the coagulum stone mass revealed the presence of all suspected stones. At this time the ureteropelvic junction obstruction was repaired using the dismembered technique. Operative blood loss was estimated at 400 cc and no intravenous transfusions were used. The patient was discharged from the hospital on postoperative day 7. Crystallographic examination of the urinary calculi (weighing 5.4 gm.) revealed calcium oxalate. Three weeks after the patient was discharged from the hospital he presented to the office complaining of nausea, fatigue, occasional diarrhea and milk colored stools. Physical examination was remarkable for scleral icterius and a tender right upper quadrant. Ultrasound of the biliary tract confirmed absence of the previously removed gallbladder, no common bile duct dilatation, no enlargement of the pancreas and no biliary stones. Pertinent laboratory studies included lactate dehydrogenase 735 (normal 0 to 250), alkaline phosphatase 283 (normal 30 to 115), serum glutamic oxaloacetic transaminase 2,770 (normal 0 to 30) and total bilirubin 6.6 (normal 0 to 1.2). Hepatitis B surface antibody, hepatitis B core antibody, hepatitis B e antigen and hepatitis A antigen were all negative. During the next 8 weeks the liver function tests, serum bilirubin and general well being approached baseline. Reviewing the 10 donated cryoprecipitate units confirmed that were negative for human immunodeficiency virus, hepatitis B antigen and rapid plasma reagent. However, these units were not sc1·eened for the presence of elevated serum glutamate pyruvate transaminase, a presumed indicator of nonA/nonB hepatitis, nor hepatitis B core antibody. Our opinion is that the nonA/nonB hepatitis was a result of the use of the human cryoprecipitate during the coagulum pyelolithotomy despite the fact that there was no intravenous blood transfusion. We presume that there was systemic absorption of blood products injected into the renal pelvis via the periforniceal venous system.
A. M., a previously healthy 53-year-old man, presented with recent onset of asymptomatic total gross hematuria. The patient had no history of urinary complaints. Medical history was remarkable only for cholecystectomy 8 years previously. Urinalysis revealed more than 100 red blood cells per high power field, no bacteria and 5 to 6 white blood cells per high power field. Urine culture was unrewarding while cystoscopy showed blood coming from the left ureteral orifice. An excretory urogram (IVP) showed multiple calculi in the left renal pelvis and the upper major calix (fig. 1), prompt excretion of contrast medium bilaterally, and marked dilatation of the left renal pelvis and collecting system with obstruction at the ureteropelvic junction (fig. 2). The screening chemistry studies were unremarkable, including normal liver function studies and nonreactive reagin circle card test (rapid plasma reagent). It was decided to repair the ureteropelvic junction obstruction while removing the large stone burden with the aid of coagulum pyelolithotomy. A subcostal incision was used to gain access to the left inferior renal pole with the patient under nitrous oxide/ enflurane inhalation anesthesia. The dilated renal pelvis appeared to be secondary to a fibrous band crossing at the ureteropelvic junction. Approaching the pelvis posteriorly, an angiocatheter needle was placed into the pelvis and approximately 110 cc clear, yellow colored fluid were removed. After a soft silicone sling was secured just distal to the ureteropelvic junction (for purposes of preventing antegrade flow of coagulum) a mixture of thrombin, calcium chloride and 100 cc body temperature cryoprecipitate (drawn from a pool of 10 human cryoprecipitate units) was injected through the previously placed angiocatheter with strict attention to infusion DISCUSSION pressure. Infusion pressure was hand controlled by the operators avoiding excessive pressure during infusion. However, no The use of coagulum precipitate was described first by Dees in-line manometer was used during the cryoprecipitate infusion in 1943. 1 Because of its technical complexity, the use of pooled to monitor infusion pressure. human fibrinogen and a significant risk of hepatitis transmission above that of a standard blood transfusion, it was a procedure not widely used. During the next 30 years several Accepted for publication October 2, 1988. *Requests for reprints: Department of Urology, Northwestern Uniinvestigators made valuable alterations, including the use of versity Medical School, 303 East Chicago Ave., Chicago, Illinois 60611. cryoprecipitate, which was more widely available, more uniform 923
,.....--
924
--
MCVARY AND O'CONOR
FIG. 1. A, abdominal radiograph reveals multiple calculi in area of left renal pelvis and upper calix. B, tomographic cut shows large starshaped calculus in renal pelvis and multiple smaller stones in upper and lower calices.
FIG. 2. IVP shows dilated left renal pelvis and hydronephrosis consistent with ureteropelvic junction obstruction.
FIG. 3. Coagulum in shape of collecting system after having been teased from left renal pelvis.
and of reproducible strength. 2 - 6 Other major improvement s include the use of thrombin, calcium chloride and intraoperative kidney radiographs in the search for occult stones, and the screening of all blood donors for hepatitis B. 7 • 8 Cryoprecipitate is prepared by thawing a unit of fresh frozen plasma at 4C and recovering the cold-precipitate protein by
centrifugation; Cryoprecipitate is obtained as a by-product of modern standard blood component therapy and constitutes the cold precipitatable proteins, primarily fibrinogen and factor VIII. The advantages of cryoprecipitate are its ready availability in any blood bank and the economy of using an otherwise wasted resource. Additionally, the incidence of hepatitis after use of nonpooled plasma products always is less than after use of pooled preparations. 9 • 10 Before routine hepatitis B screening the disease most frequently transmitted by blood transfusion was type B viral hepatitis. It is not easy to determine the incidence of this complication because of the nonicteric forms of the disease but the incidence is lower when blood donor selection excludes high risk hepatitis carriers, drug addicts and professional donors. Reported incidence of post-transfus ion hepatitis B is 0.3 to 9 cases per 1,000 transfused units, or 0.5 to 13 cases per 100 patients transfused. The risk increases linearly with the number of units of blood transfused. More of a problem is that of nonA/nonB post-transfus ion hepatitis, which accounts for 90 per cent of the cases following transfusion of voluntarily donated blood. 11 The incubation period of hepatitis may range from 45 to 160 days, while that of nonA/nonB ranges from 15 to 160 days. Recently, the Food and Drug Administrati on has suggested that all donors be screened for elevated serum glutamic pyruvic transaminase as a possible indicator of nonA/ nonB hepatitis. Additionally, new recommenda tions from the Food and Drug Administrati on advise screening all blood donors for hepatitis B core antibody to avoid any donors who have a history of hepatitis. 12 The possibility of an anesthetic-in duced hepatitis must be considered in any postoperative patient because development of some degree of hepatic necrosis after administratio n of volatile agents has been suspected. Large retrospective studies have indicated only a small chance that halothane in combination with genetic background, exposure to drugs, reduced hepatic flow or hypoxia might lead to some liver damage. 13 Our patient received enflurane, which is not an agent associated with liver dysfunction. 14 Less likely infectious agents responsible for the hepatitis in our patient include syphilis, Epstein-Barr virus and cytomegalovirus. The patient was screened for syphilis (nonreactive rapid plasma reagent) as were all blood products used. Cytomegalovirus is an isolated rare cause of hepatitis in the nonimmunocompromised patient. Thus, it is unlikely to be the underlying cause. Epstein-Barr virus is a rare cause of clinical hepatitis with several clinical hallmarks not found in our patient (sore throat, pharangeal inflammation , tender lymphadenopathy and short clinical prodrone). Jaundice is a rare complication of the Epstein-Barr virus (less than 3 per cent) and when it occurs it is accompanied by mild elevations of liver function tests (unlike our patient). More obvious in our patient was the lack of increased white blood cells, lymphocytes and atypical lymphocytes (both absolute and relative number). 15 Coagulum pyelolithotomy has been considered a reasonably safe operation for properly selected patients. However, Pence and associates described a patient undergoing pyelolithotomy who suffered a fatal pulmonary embolus during the procedure. 16 It was hypothesized that the thrombin injected into the renal pelvis was absorbed via the periforniceal venous system and led to the fatal event. They also described an animal model correlating the volume of coagulum above that necessary for filling the pelvis and concentration of thrombin with the incidence of detectable systemic absorption. Bhagavan and associates demonstrated that pyelovenous backflow occurs with an injection pressure above 30 mm. Hg and, therefore, by keeping injection pressure low one might avoid any systemic absorption.17 By using sterile in-line pressure transducers one would be able to control infusion pressure more accurately. In recent years the use of coagulum pyelolithotomy has decreased largely because of percutaneous nephrolithoto my and
TRANSMISSION OF NONA/NONB HEPATITIS DURING COAGULATION PYELOLITHOTOMY
extracorporeal shock wave lithotripsy. Its use will continue to have a role in the urological armamentarium but only under special circumstances, such as that outlined previously. The possibility of hepatitis transmission with this technique is a reality but it can be overcome with the use of autologous cryoprecipitate. One unit of whole blood can yield 10 to 20 cc precipitated proteins. This blood donation technique is available but requires the patient to donate approximately 1 week before the scheduled operation. 9 To produce the 100 cc autologous cryoprecipitate our patient would have been required to donate 5 to 10 units of blood preoperatively. Hopefully, most coagulum pyelolithotomies will not demand such quantities. Obviously, cases when large volumes of cryoprecipitate are needed may require the patient to accept some donor units. However, cryoprecipitate units, once donated, may be kept for extended periods and allow for large numbers of units to be used autologously. In summary, we report a case of nonA/nonB hepatitis subsequent to the use of intrarenal cryoprecipitate. Post-transfusion hepatitis epidemiology is reviewed briefly. We advise the use of autologous cryoprecipitate donation for any elective coagulum pyelolithotomy. REFERENCES 1. Dees, J. E.: The use of an intrapelvic coagulum in pyelolithotomy:
a preliminary report. South. Med. J., 49: 503, 1943. 2. Patel, V. J.: The coagulum pyelolithotomy. Brit. J. Surg., 60: 230, 1973. 3. Marshall, S.: Commercial fibrinogen, autogenous plasma, whole blood and cryoprecipitate for coagulum pyelolithotomy: a comparative study. J. Urol., 119: 310, 1978. 4. Broecker, B. H. and Hackler, R. H.: Simplified coagulum pyelolithotomy using cryoprecipitate. Urology, 14: 143, 1979. 5. Fischer, C. P., Sonda, L. P. and Diokno, A. C.: Use of cryoprecipi-
925
tate in extracting renal calculi. Urology, 15: 6, 1980. 6. Marshall, S.: Coagulum pyelolithotomy. Urol. Clin. N. Amer., 10: 659, 1983. 7. Beck, A. D.: Intraoperative radiography in conservative surgery for renal calculi. J. Urol., 110: 494, 1973. 8. Boyce, W. H.: The localization of intrarenal calculi during surgery. J. Urol., 118: 152, 1977. 9. Borucki, D. T.: Blood Component Therapy: A Physician's Handbook, 3rd ed. Washington, D. C.: American Association of Blood Banks, 1982. 10. Harrison, R. C.: Blood component therapy. In: Introduction to Anesthesia: The Principles of Safe Practice, 6th ed. Edited by R. D. Dripps, J. E. Eckenhoff and L. D. Vandam. Philadelphia: W. B. Saunders Co., chapt. 23, pp. 270-282, 1982. 11. Dienstay, J. L., Nanda, J. R. and Koff, R. S.: Acute hepatitis. In: Harrison's Principles of Internal Medicine, 9th ed. Edited by K. J. Isselbacher, R. D. Adams, E. Braunwald, R. G Peterdorf and J.D. Wilson. New York: McGraw Hill Book Co., part 5, sect. 6, pp. 1459-1470, 1980. 12. Memorandum: American Association of Blood Banks, Arlington, Virginia, May 27, 1987. 13. Badden, J. M. and Rice, S. A.: Metabolism and toxicity of inhaled anesthetics. In: Anesthesia, 2nd ed. Edited by R. D. Miller. New York: Churchill Livingstone, vol. 1, chapt. 22, p. 716-726, 1986. 14. Lewis, J. H., Zimmerman, H. J., Ishak, K. G. and Mullick, F. G.: Enflurane hepatotoxicity. A clinicopathologic study of 24 cases. Ann. Intern. Med., 98: 984, 1983. 15. Niederman, J. C.: Infectious mononucleosis. In: Infectious Diseases: A Modern Treatise of Infectious Processes, 3rd ed. Edited by P. D. Hoeprich. Philadelphia: Harper & Row Publishers, chapt. 137,pp. 1205-1211,1983. 16. Pence, J. R., II, Airhart, R. A., Novicki, D. E., Williams, J. R. and Ehler, W. J.: Pulmonary emboli associated with coagulum pyelolithotomy. J. Urol., 127: 572, 1982. 17. Bhagavan, B. S., Wenk, R. E. and Dutta, D.: Pathways of urinary backflow in obstructive uropathy: demonstration by pigmented gelatin and Tamm-Horsfall uromucoprotein markers. Hum. Path., 10: 669, 1979.