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The blood pressure response to operative treatment in 502 patients with renal artery stenosis and coexisting hypertension was as follows: 51% cured, 15% improved, and 34% failure. The operative mortality was 5.9%. Patients with unilateral fibromuscular disease had a favorable blood pressure response (79.8%) more frequently than the patients with unilateral atherosclerosis (63.4%). In patients with bilateral stenosis, a favorable result occurred in 56%. The anatomic failure rate due to thrombosis of arterial reconstructions, as well as the operative mortality, varied considerably between institutions. If preoperative diagnostic studies demonstrated significant functional disparity between kidneys, and if the operation was anatomically successful, then approximately 80% of these patients were benefited by surgical intervention.(JAMA 231:1043-1048, 1975)

There were 104 major complications (13.1%) and 34 deaths (5.9%) among 502 patients with evidence of renovascular, disease who underwent 577 operative procedures. The operative mortality rate in patients with atherosclerotic renovascular disease was 9.3% vs 3.4% with fibromuscular hyperplasia.Important determinants of renovascular operative mortality are (1) cause of disease, (2) presence of coronary artery disease, (3) presence of bilateral renal functional impairment, (4) the complexity of the renal operative procedure, and (5) concurrent extrarenal surgery.(JAMA 231:1148-1153, 1975)

The Hypertension Detection and Follow-up Program (HDFP) previously described a significant reduction in five-year, all-cause mortality in its intensively treated stepped care (SC) group relative to its referred care (RC) control group. At the time this finding was described, a proportion of the SC cohort had been treated for periods as long as 6.7 years, but comparable RC and SC mortality data beyond five years were not available. These data, which are described herein, indicate that the 6.7-year life-table mortality rates were 95.1/1000 participants for SC vs 116.3/1000 participants for RC, a larger mortality difference than was observed at five years. This favorable finding for SC extended to all major subgroups, including white women and those aged 30 to 49 years at trial entry. Six months after the close of the treatment trial, a two-year posttrial surveillance study, which extended mortality follow-up to 8.3 years, was conducted. The posttrial use of antihypertensive medication declined in SC and increased in RC participants so that by the end of the posttrial period, there was little difference in the percentages of SC and RC participants taking medication. Control of blood pressure, indicated by mean diastolic blood pressure and by percent of participants with a pressure of 90 mm Hg or less, was slightly better for SC than for RC participants (SC group, 86.5 mm Hg and 68% controlled; RC group, 87.8 mm Hg and 62% controlled). The absolute mortality advantage found at 6.7 years persisted and increased throughout the posttrial period of follow-up despite discontinuation of the formal SC therapy program. It is postulated that regression of hypertensive end-organ changes brought about by the more effective SC treatment caused this favorable outcome.(JAMA 1988;259:2113-2122)

Abnormal urographic features were present in 60.7% of 250 patients with bilateral disease. The urogram was relatively insensitive in the minority of patients whose lesions were of approximately equivalent severity bilaterally. In bilateral renovascular disease, the urogram demonstrated some surgical prognostic value that was not evident in unilateral renovascular disease. Furthermore, in patients with bilateral disease, the urogram was helpful in deciding between unilateral or bilateral operation.(JAMA 237:1706-1709, 1977)

The prognostic value of renal vein and peripheral renin levels was analyzed in 66 patients with unilateral renal artery stenosis who underwent corrective surgery. Patient selection for operation was independent of renin results. Fifty-three percent of those with confirmed renovascular hypertension had renal vein renin ratios less than 2.0, ie, within the 95% confidence limit for the control group of 82 patients with essential hypertension. Thirty-four patients with clearly lateralizing renin data (ipsilateral:contralateral ≥1.5 and contralateral:peripheral ≤1.3) were benefited by operation, but 23 additional patients with nonlateralizing data also benefited. No proposed scheme for renin data analysis detected more than 75% of those with renovascular hypertension.Although lateralizing renin data are highly predictive of operative benefit, nonlateralizing data do not necessarily herald operative failure and should not be dogmatically used to exclude surgical intervention.(JAMA 238:2617-2620, 1977)

In this study, 67 cases of renovascular hypertension were followed from one to six years after vascular repair or nephrectomy. Twenty-five patients became normotensive and another 30 patients showed significant improvement. There were 18 failures and three deaths in this series. The results obtained in this series were compared with those obtained from other centers and have been analyzed in regard to the percentage of cases treated by nephrectomy versus those treated by arterial reconstruction procedures. The data indicate certain pitfalls in the preoperative diagnosis of renovascular hypertension, employing the currently available tests of radiorenography, intravenous urography, and divided kidney studies.

Observations over 2 to 14 months in 19 adults with various unrelenting renal diseases considered to have immunological basis suggest that azathioprine (Imuran) combined with high doses of prednisone may have value in treating certain of these disorders. Good results occurred in steroid-resistant or steroid-intolerant nephrotic syndrome, particularly with minimal pathological glomerular changes. In lupus nephritis, the condition of three of four patients improved when steroids alone had been ineffective. In subacute and chronic glomerulonephritis a few patients experienced improvement, but the condition of most was unchanged or worse. Where steroidal side effects were a problem, azathioprine allowed a reduction or discontinuance of steroids, with continuing favorable results. Hematological and gastrointestinal symptoms were the major side effects encountered, and were not severe except in patients with advanced renal failure.

Complications of earlier methods of peritonea! dialysis are eliminated by a new technique of intermittent dialysis utilizing commercially prepared electrolyte solutions, special catheters, and a "closed system" of infusion and drainage. This was mechanically successful in 76 instances. Conditions treated satisfactorily included acute renal failure, barbiturate poisoning, intractable edema, hepatic coma, hypercalcemia, and chronic uremia. Although less efficient than the artificial kidney on an hourly basis, peritoneal lavage is easier to use over extended periods of time.

IN APRIL, 1966 the first normal delivery at term after a kidney homotransplantation occurred at the Medical College of Virginia.1 On Sept 19, 1966, the second such event in this country occurred at the University of California, Los Angeles, Center for the Health Sciences. The similarity between the two cases is noteworthy. Both women had received a kidney homograft from a living relative a little more than a year earlier. Both patients maintained excellent renal function throughout pregnancy; both had normal vaginal deliveries at term, and in each case the newborn child appears to be entirely normal, despite maintenance of immunosuppressive therapy during pregnancy.Report of a CaseA 35-year-old married woman (023-10-30) was admitted to the UCLA Hospital on June 18, 1965, for a possible kidney homotransplantation. In April 1964 her blood urea nitrogen was 60 mg/100 cc, and she required several transfusions for anemia. A diagnosis of

Thirty-four patients with chronic renal insufficiency were instructed to subsist on a 20-gm balanced lowprotein diet during a 21-month study period. There was a 22% incidence of inability to follow this strict regimen. Patients who adhered to the diet and had adequate renal function as judged by urea nitrogen clearance of greater than 1.5 cc/min experienced improvement in uremic symptoms. Complications of this regimen included hyperkalemia and edema. Metabolic acidosis was prevented by the use of orally administered calcium carbonate supplements. Return of uremic symptoms generally occurred when urea nitrogen clearance decreased below 1.5 to 1.0 cc/min or when urine volume decreased below 1 liter/24 hr. The duration of remission from uremic symptoms depends on prevention of deterioration in renal function and cooperation of the patients in adhering to this special diet.

Urograms were analyzed and correlated with arteriographic findings and therapeutic results in order to evaluate the reliability of the urogram screening procedure for unilateral renovascular disease and its usefulness in predicting surgical results. Major urographic features were disparity in renal length, calyceal appearance time, and concentration on late films. Minor urographic features analyzed included ureteral notching, decreased volume of the collecting system, parenchymal atrophy, and renal ptosis. All the major urographic features occurred more frequently in the presence of renovascular disease than in a comparable population of patients with essential hypertension. Delayed appearance time seemed to be the single most valuable urographic feature.The urogram was considered to be a satisfactory method for diagnosing the presence or absence of moderate or severe renovascular disease. Urography alone did not enable discrimination between patients who would respond favorably to surgery and those who would not.

Clinical characteristics of 175 patients with renovascular hypertension cured by surgery were compared with those of 339 patients with essential hypertension. Significant variables included abdominal or flank bruit, age, sex, race, duration and acceleration of hypertension, family history, symptoms, history of arterial occlusive disease outside of the kidney, body habitus, systolic blood pressure, orthostatic change in blood pressure, severity of retinopathy, cardiomegaly, blood urea nitrogen, serum creatinine and cholesterol levels, serum potassium and carbon dioxide contents, urinary casts, proteinuria, and bacteria. Some of the differences between the two populations were no longer apparent after matching 131 pairs of patients according to age, sex, race, and diastolic blood pressure.Patients cured by surgery were compared with patients who were improved, who failed to respond, and who had surgical deaths. In patients with atherosclerotic lesions, those who failed to respond had hypertension of longer duration and were more likely to show left ventricular hypertrophy than the cured patients. Those with surgical death had more widespread atherosclerosis, cardiac damage, and renal functional impairment.

The Radiology Study Group of the Cooperative Study of Renovascular Hypertension was concerned with all aspects of technique and interpretation of the intravenous urogram and the arteriogram.The major urographic features, kidney length, calyceal appearance time, and concentration of contrast medium, as well as minor features (ureteral notching, kidney width, calyceal length, radiographic density, calyceal and pelvic configuration, parenchymal length, decreased pyelocalyceal size and renal ptosis) were defined and evaluated.Arteriographic evaluation included the type and volume of contrast agent, route of administration, and complications. The number of renal arteries and degree of stenosis evaluation included poststenotic dilatation; segmental or supplemental renal artery stenosis; the etiology of the stenosis; presence of collateral vessels; renal length, width, and cortical thickness; cortical defects; and nephrosclerosis. Intraobserver and interobserver discrepancies were discussed.

This report on the Cooperative Study of Renovascular Hypertension, includes details of its purposes, organization, diagnostic studies, statistical methodology, and demographic data. Of 2,442 patients studied, 1,128 subjects were judged to have primary (essential) hypertension, 880 renovascular disease, 355 parenchymal kidney disease, and 79 miscellaneous disorders. There were 577 operative procedures in 502 patients with renal arterial disease. There were 384 patients with follow-up of at least one year postsurgery. A unique aspect of this multidisciplinary cooperative study was its decentralization into special study groups for analysis and refinement of data. This and subsequent publications should provide prospective definitions of "renovascular hypertension," as well as an objective basis for the diagnosis and treatment of this condition.

To assess the result of any treatment of patients for the relief of hypertension, it is necessary to ascertain within what limits the blood pressures may vary in a series of hospital diastolic supine blood pressures. Only cases with at least nine hospital supine diastolic pressures were used. The population was then stratified into subjects with renovascular lesions and those with primary essential hypertension. The standard deviation for hospital diastolic supine blood pressures was found to be 10.23 mm Hg, regardless of the etiology of the hypertension. The large sample size in this report, with the corresponding stability of the estimate of blood pressure variability, enables these results to be used as a basis for definitions of therapeutic results.

Arteriograms in 2,374 patients in the Cooperative Study of Renovascular Hypertension revealed renovascular disease in 884. The etiology of the renal arterial lesions was atherosclerosis in two thirds and fibromuscular hyperplasia (FH) in one third.A favorable response to surgery was higher in FH than in atherosclerosis. In atherosclerosis where lesions had less than 50% reduction in luminal diameter, favorable response to surgery was 43%, as contrasted with 68% in patients with more than 50% reduction. In FH, 72% of patients with stenosis of less than 50% had a favorable response to surgery. The highest incidence of favorable response (91%) occurred in patients with FH whose stenosis was judged to be greater than 80%.There is no relationship of surgical response to the presence or absence of collateral circulation or poststenotic dilatation. The arteriogram has only limited value in predicting the response to surgery.

Hypertensive crises were reported in three patients with hypertension associated with underlying renovascular occlusive disease during reduction of antihypertensive therapy. In each case, rebound hypertension was observed during clonidine hydrochloride withdrawal. Therapy with propranolol hydrochloride and diuretics had also been discontinued in two of the three patients. This and other reports of rebound hypertension during clonidine withdrawal are contrasted with the absence of reports of this syndrome in the setting of cessation of β-adrenergic blockade therapy. This suggests that the discontinuation of clonidine therapy was primarily responsible for the hypertensive crises herein described. It is further concluded that rebound hypertension may follow gradual as well as abrupt reduction of clonidine dosage, and that patients with renovascular hypertension may be at greatest risk.(JAMA 238:1734-1736, 1977)

The medical and surgical management of the septic patient with suppurative otitis media presents a distinctly individualized problem, one which does not submit to the simple solution of adapting the patient to one standardized procedure. I use the expression "the septic patient with otitis media" rather than "the patient with otitic sepsis" in order to emphasize the frequently forgotten fact that the otitis media may be an incident in the course of an infection elsewhere in the body responsible for the patient's sepsis.The term "sepsis" is used rather broadly to represent a clinical picture manifesting numerous variations. It cannot have the concreteness indicated by such terms as bacteremia and septicopyemia. In the present discussion those patients have been considered septic in whom, during the course of an otitis media, leukocytosis has developed with intermittent fever rising to 103 F. or higher at least once daily and who have continued

THE FIRST successful arterial repair for renovascular hypertension in man was reported in The Journal by Freeman and associates in 1954.1 Subsequently, arterial repair (or replacement) has become a widely accepted therapy for this condition. Since many candidates for such an operation are young, it is desirable to know how long the repaired or reconstructed renal artery can provide for adequate blood flow to the kidney. Unfortunately, this kind of information is scarce. The following report demonstrates that a repaired artery can provide adequate flow of blood to the kidney for as long as 20 years.Report of a CaseA 23-year-old woman came to the emergency room of UCLA Hospital on Oct 4, 1955, for treatment of a bee sting. Her blood pressure was 200/130 mm Hg. A subsequent examination showed stenosis of the right renal artery. Ureteric catheterization studies showed diminished urine flow and decreased phenolsulfonphthalein (PSP)

Experience with three patients cared for by one group over a 12-month period suggested to us that rebound hypertension with hypertensive crisis in the setting of clonidine withdrawal was not a rare event and, indeed, compelled us to report our observations.The hypothesis that a surge of increased sympathetic activity associated with clonidine withdrawal in the presence of β-adrenergic blockade would result in unopposed, potentiated α-adrenergic vasoconstriction is well reasoned, and as we mentioned in our article, it has been suggested by other authors.1,2We agree that careful thought must be given to the discontinuation of antihypertensive therapy with clonidine, in combination or alone. This appears to us to be particularly important in persons with renovascular or high-renin essential hypertension.

True neuralgia of the superior laryngeal nerve is a distinct clinical entity comparable to trigeminal and glossopharyngeal neuralgia. It is characterized by paroxysms of unilateral, lancinating pain, which radiates from the side of the thyroid cartilage to the angle of the jaw and sometimes to the ear. There is a trigger zone at the plica of the nerve in the pyriform sinus. The pain is ordinarily initiated by swallowing but can be produced by touching the trigger zone with a probe. The other objective finding is a pressure point on the skin surface just above and lateral to the thyroid cartilage, where the sensory branch of the nerve pierces the hyothyroid membrane. Between the seizures, which may last from a few seconds to a minute, the patient is free from discomfort. As in other cranial nerve neuralgias, the attacks usually appear after middle age and increase in frequency and intensity.

The Kidney is a collection of 28 individual essays varying greatly in length and completeness, dealing with specific areas of clinical, pathologic, or physiologic aspects of kidney disease. Of the 33 contributors, 24 are pathologists. The first of three major sections, comprising roughly 60% of the book, contains 16 chapters covering such diverse topics as normal and abnormal development, acute renal failure, pathogenesis of pyelonephritis, and spontaneous renal disease in animals. A second section, on immunological injury of the kidney, contains five relatively brief essays, two concerned with immunological aspects of glomerulonephritis, three with renal transplantation. The last section, 78 pages long, "Symposium on Geographic Pathology of Renal Disease," has a somewhat misleading title.Whoever anticipates an orderly and comprehensive survey of pathologic physiology and anatomy of the kidney will be disappointed. Large and important areas are either completely neglected or treated very superficially; conversely, other topics are dealt with