Conflicting evidence surrounds clinical outcomes in obese individuals after transplantation; nonetheless, many are denied the opportunity to receive a transplant. Allografts with complex vascular anatomy are regularly used in both deceased and living donor settings. We established the risk of transplanting kidneys with multiple renal arteries into obese recipients. A retrospective analysis of data from 1095 patients undergoing renal transplantation between January 2004 and July 2013 at a single centre was conducted. Of these, 24.2% were obese (body mass index >30 kg/m(2)), whereas 25.1% of kidneys transplanted had multiple arteries, thereby making the transplantation of kidneys of complex anatomy into obese recipients a relatively common clinical occurrence. Vessel multiplicity was associated with inferior 1-year graft survival (85.8.% vs 92.1%, P = .004). Obese patients had worse 1-graft survival compared to those of normal BMI (86.8% vs 93.8%, P = .001). The risk of vascular complications and of graft loss within a year after transplantation were greater when grafts with multiple arteries were transplanted into obese recipients as compared to their nonobese counterparts (RR 2.00, CI 95% 1.07-3.65, and RR 1.95, CI 95% 1.02-3.65). Additionally, obese patients faced significantly higher risk of graft loss if receiving a kidney with multiple arteries compared to one of normal anatomy (RR 1.97, 95% CI 1.02-3.72). Thus, obese patients receiving complex anatomy kidneys face poorer outcomes, which should be considered when allocating organs, seeking consent, and arranging for aftercare.

Over a 5-year period a prospective audit was carried out on 1131 patients undergoing surgery for abdominal aortic aneurysm (AAA) in the northern region. A total of 470 operations was performed in teaching hospitals and 661 in district hospitals; emergency operations accounted for 41.5 per cent. The overall mortality rate was 25.8 per cent; for emergency cases this value was 50.0 per cent. Mortality rates for elective surgery were 3.9 per cent in teaching and 12.0 per cent in district hospitals. Patients with ruptured AAA admitted via the accident and emergency department had a higher mortality rate (64.3 per cent) than those admitted by their general practitioner (49.5 per cent) or those referred from the urology department (18.8 per cent). In all, 73 (6.5 per cent) patients were admitted with an alternative diagnosis, ranging from collapse of unknown cause (25) to torsion of the testes (one) and colonic obstruction (one). Age had a profound effect on mortality rates. For emergency cases the mortality rate varied from 47.0 per cent (in teaching plus district hospitals) in those aged less than 80 years to 70.1 per cent in those 80 years or over (chi 2 = 7.22; P = 0.007). For elective surgery the mortality rate varied from 7.6 per cent (in teaching plus district hospitals) in those under 80 years to 23.8 per cent in those 80 years or over (P = 0.0006). The overall mortality rate of 25.8 per cent is significantly less than that quoted in the Confidential Enquiry into Perioperative Deaths report of 1987. Furthermore, elective patients over 80 years of age may expect a survival rate of 76 per cent and, in the absence of major medical contraindications, should not automatically be denied surgery. Importantly, it is of note that this prospective audit identified 31 per cent more cases than recognized by regional audit data.

Alendronate (4-amino-1-bydroxybutylidene bisphosphonate) is a novel amino bisphosphonate that is being developed for the treatment of osteolytic bone disorders such as osteoporosis. As part of a 2-year carcinogenicity study, we investigated the morphologic and biomechanical effects of long-term alendronate (ALN) therapy, given throughout skeletal growth, maturation, and aging, on rat vertebrae and femora. Three treatment groups, receiving either deionized water, low- (1.00 mg/kg), or high-dose (3.75 mg/kg) ALN, were given daily oral treatment for 105 weeks. Results from mechanical tests indicate that ALN therapy (in males) increased the vertebral ultimate compressive load by 96% in the high- and 51% in the low-dose groups when compared with controls. ALN similarly increased the male ultimate femoral bending load by 59% in the high- and 31% in the low-dose groups. Vertebrae and femora from female rats treated with both high- and low-dose ALN also failed at significantly higher loads than controls, but no differences were seen between low- and high-dose groups. Morphologic analysis of both male and female vertebrae revealed a dose-dependent increase in area fraction of bone. Rats receiving high-dose ALN had a greater area fraction of bone than those receiving low doses. Both groups were greater than controls. Thus, the administration of ALN resulted in increased femoral cortical bending load when compared with control animals, as well as increased vertebral ultimate compressive load commensurate with a dose-related preservation of vertebral bone. We therefore conclude that long-term ALN treatment preserves the structural and morphologic properties of both cortical and trabecular bone in rats and, with further study, may provide a valuable alternative to current therapy for the treatment of osteoporosis.

Successful islet allografts can be established in rats bearing long surviving renal allografts, without additional immunosuppression, when kidney and islet donor animals are of the same strain. The applicability of such a scheme to clinical practice has been investigated in a large animal model of diabetes: the pancreatectomized dog. Eight dogs with previously established renal allografts and immunosuppressed with cyclosporin A received islet allografts from their respective original kidney donors. The median islet graft functional survival was only 10·5 days, significantly less than for six similarly immunosuppressed dogs receiving islet allografts alone (48·5 days, P < 0·05). Three of the sequentially transplanted dogs had had no renal graft rejection episodes before islet transplantation, yet their islet grafts were all rejected within 19 days. In the pancreatectomized dog, prior donor specific renal transplantation has an adverse effect upon subsequent islet graft survival.

Eight dogs with previously established kidney allografts, immunosuppressed with cyclosporin A, received islet allografts from their respective original kidney donors. The median islet-graft functional survival was only 10.5 days, significantly less than for six similarly immunosuppressed dogs receiving only islet allografts (48.5 days, P < .05). Three of the eight dogs that received sequential kidney and islet allografts had experienced no kidney-graft rejection episodes before islet transplantation, but their islet grafts were all rejected within 19 days. In the pancreatectomized dog, prior donor-specific kidney transplantation has an adverse effect on subsequent islet-graft survival.

The plasma sodium concentration, [Na]P, falls following major surgery and this fall is exacerbated by the administration of sodium-free or sodium-low intravenous fluids in the postoperative period. As a prelude to prospective, but controlled, studies we observed the range of [Na]P on admission for surgery in 477 patients. In 309 patients the extent of the change in [Na]P by the first postoperative day (delta [Na]) was related to the severity of the operation undergone (minor, moderate or major) and the volume of potentially hypo-osmolar intravenous fluid given. The mean admission [Na]P was significantly lower with increasing severity of proposed operation. A highly significant fall occurred in [Na]P following surgery of every grade; such falls in [Na]P were seen even when no potentially hypo-osmolar fluids were administered. A significant inverse relationship between admission [Na]P and delta [Na] was demonstrated. We conclude that [Na]P falls following surgery of any severity and that such falls occur even when exogenous dilution cannot be implicated as a cause.

Thirty-two patients with 37 carotid body tumours, seen in the Vascular Unit at the Royal Victoria Infirmary, Newcastle upon Tyne between 1956 and 1985 are reviewed. Twenty-six of the tumours were treated by surgical excision. There were no peri- or postoperative deaths, but one patient developed a permanent hemiplegia following surgery (3.8 per cent); cranial nerve palsy occurred in five patients (19.2 per cent). There were no malignant tumours although in one patient, histology of the resected specimen showed the presence of local lymph node invasion (3.8 per cent). In the 7 patients who did not undergo surgery, 3 have been lost to follow-up; the remainder have not shown any significant increase in the size of the tumour. One patient was treated by radiotherapy. It is concluded that surgical excision is the treatment of choice, though observation may be preferred for the older patient with a symptomless, slow-growing tumour. To help reduce the risk of hemiplegia (the most serious complication of surgery) a meticulous surgical technique is necessary and heparin, intraluminal shunting and facilities for arterial repair and grafting must be at hand.