Candida arteritis in kidney transplant recipients: case report and review of the literature.

Multi-organ procurement is a risk factor for contamination of preservation fluid with intestinal flora including fungi (e.g., Candida). Transmission of fungal species to the graft vessel can cause mycotic arteritis. This is a very rare but life-threatening complication of renal transplantation. We present 2 cases of renal transplant recipients from the same multi-organ donor. Both recipients suffered from severe hemorrhages from renal graft anastomosis and renal artery pseudoaneurysm due to Candida albicans arteritis (CAA). The culture of the preservation fluid revealed growth of Escherichia coli, but neither preservation fluid nor multiple routine blood cultures performed before hemorrhagic complications revealed fungal growth (media non-selective for fungal growth were applied). The first recipient suffered from sudden severe hemorrhage in the area of graft anastomosis on day 10 post surgery (without any preceding clinical or radiological symptoms). This led to urgent surgery and graftectomy, which was complicated by cardio-respiratory arrest with resuscitation in the operating room; despite resuscitation, irreversible brain damage, and subsequent death occurred in the intensive care unit (ICU) 2 weeks later (on day 24 after transplantation). The second patient underwent urgent vascular surgery on day 22 (after transplantation), because of hemorrhage from a pseudoaneurysm of the graft artery. She required repeated vascular operations, extended antimicrobial and antifungal therapy, and ICU monitoring and, despite these interventions, she died on day 80 after transplantation as a result of Pseudomonas aeruginosa sepsis. Arteritis of the renal artery in both patients was caused by C. albicans. This was confirmed by histopathology: infiltration of renal artery with budding yeast forming pseudohyphae (Case 1), and the presence of C. albicans in the culture of the renal artery and surrounding tissue (Case 2). We conclude that organ preservation solution should be cultured with use of media selective for fungal growth. As soon as the positive culture is detected, appropriate measures protecting patients against CAA should be undertaken.

Pancreatic remnant fate.

There is eternal discussion on the best surgical method of pancreatoduodenectomy and reconstruction method. Several different methods of pancreatic stump anastomosis exist. The most popular argument taken into account in the discussion is the frequency of early postoperative complications. Relatively fewer papers analyse the late functional outcome of pancreatic surgery and the method of anastomosis employed. Authors presented short series of 12 patients after pancreatic surgery with analysis of pancreatic remnant morphology and function. Pancreatic remnant volume, pancreatic duct distension and stool elastase-1 test were analysed. There was no correlation of pancreatic exo- or endocrine insufficiency with the volume of pancreatic remnant or the kind of surgery or anastomosis performed.

Postoperative PTH measurement as a predictor of hypocalcaemia after thyroidectomy.

BACKGROUND: Hypocalcaemia after thyroidectomy is the most common postoperative complication, with a reported incidence from 0.5% to even 50% of the operated patients. Hypoparathyroidism could be a result of careless or inadequate preparation during the surgical procedure. There is a variety of proposed options for the prediction of the incidence of hypocalcaemia. The most effective of them are the peri-operative and intra-operative measurements of the parathyroid hormone (PTH) level. METHODS: A prospective study was performed on 100 patients who underwent total thyroidectomy from January 2007 to June 2008. The total calcium level and intact human PTH (iPTH) levels were measured 24 hours before as well as 1 hour and 24 hours after the surgery. THE AIM: The goal of the study was to assess the potential correlation between the iPTH levels after the operation and the development of hypocalcaemia. The possible prediction value of postoperative iPTH levels was to be assessed. RESULTS: We have presented a significant correlation between early iPTH measurement and the risk of hypocalcaemia. Moreover, a significant correlation between the iPTH level one hour after operation with the calcium level 24 hours after the operation was demonstrated. CONCLUSION: Early postoperative assessment of iPTH levels can be used to identify the group of patients at risk of hypocalcaemia after thyroidectomy. Pre-emptive calcium supplementation can lead to the avoidance of complications causing prolonged hospital stay and most importantly to prevent severe hypocalcaemia.

Decrease in serum protein carbonyl groups concentration and maintained hyperhomocysteinemia in patients undergoing bariatric surgery.

BACKGROUND: Human obesity is associated with oxidative stress but the factors contributing to the increase of reactive oxygen species (ROS) production remain unknown. We evaluated the association between serum homocysteine concentration, which may increase ROS production, and serum protein carbonyl groups concentration before and after bariatric surgery. METHODS: Serum protein carbonyl groups and serum homocysteine concentrations, as well as obesity markers, were compared in 18 obese patients before and 6 months after bariatric surgery. Ten healthy individuals with normal body mass index (BMI) served as controls. RESULTS: Before bariatric surgery, obese patients displayed approximately 50% higher serum protein carbonyl groups concentration than control subjects. After surgery, serum protein carbonyl groups concentration decreased and matched values observed in controls. Serum homocysteine concentration was also elevated in obese patients, but in contrast to protein carbonyl groups, did not change after surgery. The body weight, BMI, HOMA-IR, serum leptin, triacylglycerols, LDL/HLD cholesterol ratio, insulin, and glucose concentrations were higher in obese patients as compared to controls, and decreased after bariatric surgery. CONCLUSIONS: This study demonstrates that bariatric surgery has protective effect on oxidative protein damage and improves several laboratory parameters including serum lipid concentration and insulin resistance. However, bariatric surgery does not cause a decrease in serum homocysteine concentration, a risk factor for the development of cardiovascular diseases. Collectively, the results presented in this paper suggest that serum homocysteine concentration is not directly associated with oxidative stress in obese patients after bariatric surgery.

Quality of life after surgical treatment of pancreatic cancer.

BACKGROUND: This study was designed to assess postoperative changes in the quality of life (QoL) of patients after surgical treatment for pancreatic cancer. MATERIAL AND METHODS: QoL was analyzed in a prospective single-centre study that included 54 patients with pancreatic cancer. Patients with potentially resectable tumours underwent pancreaticoduodenectomy (PD) (n = 26), a double-bypass procedure (DBP) (n = 17) or laparotomy (L) (n = 11). They were asked to complete a questionnaire before and at 1, 2, 3 and 6 months after surgery. QoL was assessed using the EORTC QLQ-C30 and EORTC QLQ-PAN26 questionnaires (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and PAN26). RESULTS: The patients did not demonstrate significant differences in the assessment of their global health status. Although, after resection, patients gave a positive assessment of most parameters in question, after DBP they reported some aggravation of most of the symptoms. The majority of patients did not have aggravated symptoms after laparotomy. CONCLUSIONS: The study has shown the value of conducting both curative and palliative resection for QoL. Bypass procedures should be performed in cases of non-resectable pancreatic cancer with accompanying jaundice and/or gastric outlet obstruction in patients with a life expectancy of at least 6 months.

New-onset Diabetes Mellitus After Kidney Transplantation-A Paired Kidney Analysis.

BACKGROUND: New-onset diabetes mellitus (NODAT) is a severe complication after kidney transplantation. It is associated with increased risk of graft failure, cardiovascular disease, mortality and infections. METHODS: We retrospectively (partially using the registry database) analyzed risk factors and clinical consequences of NODAT in patients after kidney transplantation performed at the University Transplant Centre between 2001 and 2016. To minimize the donor variability and bias, a paired kidney analysis was applied. Diabetes was defined as the need for insulin therapy for a minimum 30 days after transplantation. RESULTS: The incidence of NODAT was 7.6% (109 of 1424), but only 74 patients with NODAT had their pairs of patients without NODAT, who received kidneys from the same donor and were included to the analysis. The NODAT group was older, and with a significantly higher Charlson Comorbidity Index (2.97 vs 3.39; P = .02). The groups did not differ significantly with respect to immunosuppressive protocols and number of mismatches (2.65 vs 2.78). The incidence of acute rejection (AR; not biopsy proven) was significantly higher in the NODAT group (30% vs 13%), but the incidence of delayed graft function (DGF) was similar (40%). Creatinine concentration and estimated glomerular filration rate (using the Modified Diet in End-stage Renal Disease equation) 1-month after kidney transplantation did not differ: 1.5 vs 1.54 mg/dL and 49.3 vs 50.2 mL/min, respectively. Body mass index (BMI) was higher in the NODAT group. On multivariate analysis, factors significantly associated with NODAT were: age; AR; Charlson Comorbidity Index; and pretransplant dialysis time. BMI was higher in the NODAT group. NODAT was not a predictor of early graft loss and patient survival in the short-term analysis. CONCLUSION: AR, older age, higher comorbidity index, and BMI were risk factors for NODAT. We did not identify an influence of NODAT on early graft function and loss, but further analysis with a longer follow-up is necessary.

Ureteric Stenting in Kidney Transplant Recipients, Gdansk Centre Experience, Poland.

BACKGROUND: The role of ureteric stenting in kidney transplant recipients is still debatable. Stenting can reduce the incidence of urine leaks and ureter stenosis, but can be also associated with specific complications, particularly urinary tract infections (UTIs). MATERIAL AND METHODS: To estimate the influence of ureteric stenting on urological complications in kidney transplantation (KTx), we retrospectively analyzed all KTx performed between January 2011 and December 2016 in Gdansk Transplantation Centre, a total of 628 patients. Ureteric stenting was used in 502 patients (80%)-double-J (DJ) group. Catheters were implanted during the surgical procedure and left in situ for a mean time of 30 days. RESULT: The frequency of urinary leaks was 10 times higher in patients without stenting (10%). Ureter stenosis was also more frequent in the non-DJ group (8.7% vs 1.6%, P < .05). Multiple-regression modeling showed that the urinary not stenting was a risk factor for urinary leak (adjusted odds ratio [AOR] = 0,1; 95% confidence interval [CI]: 0.03-0.26; P < .01), ureter stenosis (AOR = 0,16; 95% CI: 0.06-0.41; P < .01), and generally reoperation after KTx (AOR = 0,46; 95% CI: 0.28-0.77; P < .01). Acute rejection and delayed graft function were equal in both groups. Mean serum creatinine concentration 1 month after transplantation was similar in both groups (1.5 mg/dL in the DJ group and 1.44 mg/dL in the non-DJ group, P > .05). UTIs were more frequent in the DJ group (22.1% vs 16.7%), but the difference was not significant. Time of hospitalization was longer in patients with UTI (34 vs 22 days, P < .05). CONCLUSIONS: Ureteric stenting can protect patients from most frequent urological complications like urine leaks and ureter stenosis. The influence of ureteric stenting on UTI development is not strong in our material.

Paired Analysis of Outcomes After Kidney Transplantation in Peritoneal and Hemodialysis Patients.

BACKGROUND: The impact of dialysis modality before kidney transplantation (hemodialysis or peritoneal dialysis) on outcomes is not clear. In this study we retrospectively analyzed the impact of dialysis modality on posttransplant follow-up. METHODS: To minimize donor bias, a paired kidney analysis was applied. One hundred thirty-three pairs of peritoneal dialysis (PD) and hemodialysis (HD) patients were transplanted at our center between 1994 and 2016. Those who received kidneys from the same donor were included in the study. HD patients were significantly older (44 vs 48 years), but the Charlson Comorbidity Index was similar (3.12 vs 3.46) in both groups. The groups did not differ significantly with respect to immunosuppressive protocols and number of mismatches (2.96 vs 2.95). RESULTS: One-year patient (98% vs 96%) and graft (90% vs 93%) survival was similar in the PD and HD patient groups. The Kaplan-Meier curves of the patients and graft survival did not differ significantly. Delayed graft function (DGF) and acute rejection (AR) occurred significantly more often in the HD recipients. Graft vessel thrombosis resulting in graft loss occurred in 9 PD (6.7%) and 4 HD (3%) patients (P > .05). Serum creatinine concentration and estimated glomerular filtration rate (using the Modification of Diet in Renal Disease guidelines) showed no difference at 1 month, 1 year, and at final visit. On multivariate analysis, factors significantly associated with graft loss were graft vessel thrombosis, DGF, and graft function 1 month after transplantation. On univariate analysis, age, coronary heart disease, and graft loss were associated with death. Among these factors, only coronary heart disease (model 1) and graft loss were significant predictors of death on multivariate analysis. CONCLUSION: The long-term outcome for renal transplantation is similar in patients with PD and HD. These groups differ in some aspects, however, such as susceptibility to vascular thrombosis in PD patients, and to DGF and AR in HD patients.

Assessment of usefulness exhibited by different tacks in laparoscopic ventral hernia repair.

BACKGROUND: Laparoscopic ventral hernia repair is becoming a popular technique with good results and fast postoperative recovery. The mesh is placed directly under the peritoneum and anchored with transabdominal sutures and tacks. However, the ideal size of the mesh covering the hernia orifice is know, nor the ideal type or amount of tacks has to be described. METHODS: To assess the forces acting on a single tack, a mathematical model of the ventral hernia was created. The force was described in reference to the surface of the hernia orifice and the pressure in the abdominal cavity. The following different types of mesh were examined in vitro: Proceed (knitted mesh), Dual Mesh (expanded polytetrafluoroethylene [ePTFE] flat mesh), and Shelhigh (biologic flat mesh). The following different tacks also were examined: Protac, Anchor, and EMS. A pig model was used to measure the forces needed to destroy the connection between mesh and tissue and to describe the place of destruction (mesh, tissue, or tack) and the force needed. RESULTS: The force acting on a single tack proportionally depends on the surface of the hernia orifice and the pressure in the abdominal cavity. The force needed to disconnect the tissue and mesh reached 8.97 +/- 0.11 N for ProTac, 2.67 +/- 0.22 N for Anchor, and 6.67 +/- 1.32 N for EMS. These values do not allow the mesh to be held in the right position when the orifice exceeds 10 cm for Protac and EMS. The disconnection of the EMS and Protac junction damages the tissue. Anchor tacks are insufficient to hold the mesh and stay in the tissue CONCLUSIONS: In the case of small hernias (diameter<10 cm) EMS or ProTac used alone are not enough to hold the mesh. Anchor is not recommended alone in any hernia.

Are mesh anchoring sutures necessary in ventral hernioplasty? Multicenter study.

BACKGROUND: Avoiding mesh fixation to the surrounding tissue in ventral hernioplasty would simplify the operation, decrease the time of the procedure, and decrease the risk of suture-related complications. METHODS: Four hospitals included 111 patients according to the common protocol for prospective clinical evaluation of sutureless ventral hernioplasty. Surgical technique involves placement of the polypropylene mesh with flat-shape memory in either the retromuscular or preperitoneal space without suture anchoring. RESULTS: Local complication rate was low (12.6%, 14 patients), postoperative pain measured according to the visual analogue scale was minimal (mean 4, range 1-8). Three recurrences (3%) were recorded. Mild scar discomfort, which did not require treatment nor limit physical activity, was recorded in 28 (25%), 18 (17%), and 11 (14%) patients at 6-month, 1- and 2-year follow-up, respectively. CONCLUSIONS: Results of the study suggest that the sutureless sublay technique is safe and effective in the treatment of ventral abdominal hernia, especially in small and medium defects.