Surgical Treatment of Hyperparathyroidism After Kidney Transplant.

Chronic renal impairment is often associated with complex bone disorders. Improvement of secondary hyperparathyroidism (HPT) is expected after kidney transplant (KT) if the glomerular filtration rate is normalized. PATIENTS AND METHODS: There were 888 KTs performed between 1996 and 2017 at our department. A total of 558 general patients have been operated on for HPT during the same period. The 2 populations had a common part: out of the 558, a total of 69 (12.4%) were in end-stage renal failure when operated on because of secondary HPT. That also means that 7.8% of all KTs were associated with HPT. Retrospective, single-center analysis was performed using the patients' medical records. The aim of our study was to analyze the results of parathyroidectomies after KT. RESULTS: Parathyroid surgery was performed on 19 patients (2.14%) because of HPT after KT. The applied surgical technique was total parathyroidectomy with autotransplant in 6 cases, subtotal parathyroidectomy in 3 cases, and selective parathyroidectomy in 10 cases. In all cases, histology revealed benign disease. Complications were observed in 10 cases (52%); there were 6 cases of postoperative hypocalcaemia (31.58%), 1 case of transient laryngeal recurrent nerve paresis (5.26%), and 6 cases of recurrent HPT (31.58%). SUMMARY: The first step of HPT management is calcimimetic drug treatment. It is essential to prevent possible complications with regular laboratory monitoring. If the proper conservative therapy is refractory or severe in complications, surgery should be chosen. If the patient is already waiting for a KT, it is worth performing the parathyroid surgery before KT. Close collaboration with endocrinologists and nephrologists is needed to achieve successful therapy.

Bacterial Infections After Kidney Transplantation: A Single-Center Experience.

BACKGROUND: Bacterial infections significantly affect graft loss and mortality after kidney transplantation (KT). We reviewed the frequencies, risk factors, and sources of bacterial infections after KT and their impact on graft and patient survivals. METHODS: The data of 154 kidney recipients who underwent transplantation from 2010 to 2015 were explored. Donor, recipient, and surgical parameters were collected, and source, type, and frequency of infectious complications, number of infective episodes, multidrug-resistant (MDR) bacteria, and the bacterial spectrum were established. RESULTS: The most common infection was urinary tract infection, which is in line with the literature. Out of the 154 recipients, 72.1% (n = 111) had at least 1 occasion of a bacterial infection episode with clinical symptoms. It occurred 0-43 months (mean, 19.5 mo) after transplantation. Ninety-three KT recipients (67.9%) developed 274 episodes of infection in the postoperative 1st year (1.8 episodes/patient/y), and 42 patients had admission to the hospital ward (5.2 d/patient/y). MDR was detected in 19.8% of the infections. CONCLUSIONS: A bacterial infection had no significant impact on survival by itself. However, in case of sepsis graft and patient survivals were lower compared with normal control subjects.

A Single-center Experience of Allograft Nephrectomies Following Kidney Transplantation.

INTRODUCTION: Approximately 10% of renal allografts fail during the first year after kidney transplantation (KT) and 3%-5% thereafter yearly. The indication and timing of allograft nephrectomy (AN) is still uncertain in some cases. The aim of this study was to reveal the ratio, etiology, and complications of AN at our center. MATERIAL AND METHODS: This is a retrospective study of all patients who underwent KT at our center between January 1, 2004 and December 31, 2014. We analysed the frequency, indications, timing, and complications of ANs. Also early and late ANs were compared. RESULTS: From 417 renal transplantations 49 ANs were performed (11.7%). The most frequent indications were chronic allograft nephropathy (25; 51%), arterial blood supply complications, like arterial thrombosis and stenosis (7; 15%), treatment-resistant acute rejection (3; 6%), and nonreparable ureter complications (3; 6%). The average time of AN since KT was 28 months. ANs were performed as an urgent setting in 16 (33%) cases, whereas it was elective in 33 cases (67%). The AN was executed within 30 days (early) in 11 (22%) cases, and thereafter (late) in 38 (78%) cases. The main indication for early AN was renal artery thrombosis (4; 37%) and chronic allograft nephropathy (25; 66%) for late AN. Surgical complications occurred in 10 cases (20; 4%). The most common was hematoma. CONCLUSION: The majority of the ANs were elective and late (more than 30 days; average time, 47 months). Leading indication was chronic allograft nephrectomy. Early ANs were urgent and life-saving in all cases.

Surgical Complications Following Kidney Transplantations: A Single-Center Study in Hungary.

Surgical complications (SCs) are still high potential causes of graft loss. The incidence has a huge amount of variations depending on many factors. Our aim was to study the postoperative technical complications following kidney transplantations (KTs) during a 5-year period between 2011 and 2015. In the observed time frame there were 47 SCs occurring in 32 (19.4%) patients of 165 KTs. Every complication was classified into 3 groups: vascular (11; 6.6%), urologic (16; 9.7%), and any others (20; 12.1%). The most common postoperative SCs in our center were hemorrhage (14; 8.5%), urinary leakage (12; 7.2%), and renal artery stenosis (6; 3.6%). Twenty-seven patients, 84% of those having had a SC, needed an intervention, mainly a surgical correction (28; 62%). Half of these interventions (21; 51%) were performed due to urologic reasons. As possible predicting factors, we studied the type of arterial and ureter anastomosis in relation to onset of vascular and urologic complications. There was no significant correlation. The same was true for any donor and/or recipient demographic parameters. However, the presence of SCs impaired both patient and graft survival. The cumulative 6-month, 1-, 3-, and 5-year patient survival rates were 97% versus 99%, 93% versus 99%, 84% versus 97%, and 84% versus 97% for patients with/without (w/wo) a SC, respectively (P = .028). The cumulative 6-month, 1-, 3-, and 5-year graft survival rates were 81% versus 96%, 77% versus 94%, 68% versus 86%, and 54% versus 86% for the same 2 groups, respectively (P = .003).

Gerundium: A Comprehensive Public Educational Program on Organ Donation and Transplantation and Civil Law in Hungary.

BACKGROUND: Organ transplantation has become an organized, routine, widely used method in the treatment of several end-stage diseases. Kidney transplantation means the best life-quality and longest life expectancy for patients with end-stage renal diseases. Transplantation is the only available long-term medical treatment for patients with end-stage liver, heart, and lung diseases. Despite the number of transplantations increasing worldwide, the needs of the waiting lists remain below expectations. METHODS: One of the few methods to increase the number of transplantations is public education. In cooperation with the University of Debrecen Institute for Surgery Department of Transplantation, the Hungarian National Blood Transfusion Service Organ Coordination Office, and the Local Committee Debrecen of Hungarian Medical Students' International Relations Committee (HuMSIRC), the Gerundium, a new educational program, has been established to serve this target. Gerundium is a special program designed especially for youth education. Peer education means that age-related medical student volunteers educate their peers during interactive unofficial sessions. RESULTS: Volunteers were trained during specially designed training. Medical students were honored by HuMSIRC, depending on their activity on the basis of their own regulations. Uniform slides and brochures to share were designed. Every Hungarian secondary school was informed. The Local Committee Budapest of HuMSIRC also joined the program, which helps to expand our activity throughout Hungary. The aim of the program is public education to help disperse disapproval, if presented. CONCLUSIONS: As a multiple effect, our program promotes medical students to have better skills in the field of transplantation, presentation, and communication skills. Our program is a voluntary program with strong professional support and is free of charge for the community.

Results of Expanded-Criteria Donor Kidneys: A Single-Center Experience in Hungary.

BACKGROUND: To ease organ shortage, many transplant centers accept kidneys from expanded-criteria donors (ECDs). Our aim was to analyze the results of ECD grafts in our center. METHODS: Data on cadaveric donors were retrospectively analyzed between January 2011 and September 2014. Definition of ECD was: (1) donor age ≥60 years, (2) donor age 50 to 59 years, and (3) the presence of 2 among the following criteria: hypertension, serum creatinine >1.5 mg/dL, or death from cerebrovascular accident. Standard-criteria donors (SCDs) were those who did not meet the criteria for an ECD. RESULTS: During the observation period, 215 cadaveric donors were reported within our region, and 14 kidneys were offered to our center from Eurotransplant. Ninety-one (40%) among the reported donors were ECDs and 123 (54%) were SCDs. The rates of delayed graft function (DGF) and acute rejection (ARE) were not influenced by transplantation of an ECD graft. The cumulative patient and graft survival rates for ECDs were comparable with those of patients who received an optimal graft. CONCLUSIONS: ECD grafts can be transplanted safely, without the increased risk of DGF, ARE, and inferior patient and graft survival, in the case of careful patient allocation, and with the use of induction therapy.

Three-year longitudinal clinical trial of arterial function assessed by a oscillometric non-invasive method in comparison with carotid sclerosis and transferrin kidney-transplanted patients.

Chronic kidney disease remains one of the main risk factors of cardiovascular disease. However, patients with kidney transplantation have better life expectancy and better quality of life compared with patients on dialysis. In patients with a well-functioning graft, the main cause of death is cardiovascular in origin. Metabolic pathways have complex effects on arterial function that can be monitored by conventional ultrasonography and with the assessment of arterial stiffness by oscillometric non-invasive technique. Forty-one primer cadaver kidney-transplanted patient were involved in a 3-year longitudinal clinical trial (21 female, 20 male; average age, 40.16 ± 12.56 years). Arterial stiffness parameters referring to rigidity of the arterial wall (pulse wave velocity [PWV], augmentation index, and pulse pressure) were investigated. Correlation between stiffness, and laboratory parameters (serum creatinine, urea, hemoglobin, albumin, cholesterine, triglycerides, transferrin, uric acid, glomerular filtration rate, and C-reactive protein) were analyzed. A non-invasive oscillometric method--Tensiomed Arteriograph--was applied to assess the arterial stiffness parameters. Statistical analysis was performed with the use of Statistica for Windows, version 8.0. A value of P < .05 was considered statistically significant for all statistical tests. We found a positive correlation between PWV and left ventricular wall thickness and a negative correlation between PWV and ejection fraction. We also found a positive significant correlation between serum level of transferrin and PWV. There was simultaneous significant progression concerning PWV and carotid artery sclerosis in a 3-year follow-up. There was no fatal cardiovascular event during the study period among our patients. All of our patients involved in this study are still alive. Our findings suggest that arterial stiffness monitoring is a reliable method to assess global cardiovascular risk among kidney-transplanted patients. The oscillometric method is convenient, fast, painless technique to monitor arterial function, which, in the case of pathological findings, proposes more frequent cardiovascular control.

Noninvasive perioperative monitoring of arterial function in patients with kidney transplantation.

Development of atherosclerosis is accelerated in kidney transplant recipients. Impaired metabolic pathways have a complex effect on the arterial wall, which can be measured by noninvasive techniques. Few data are available on the change of stiffness parameters in the postoperative course, so in this study we analyzed the stiffness parameters of kidney transplant recipients during the perioperative period. Seventeen successful primary kidney transplant patients with uneventful postoperative period (7 woman, 10 men; 46.16 ± 12.19 years) were involved in our short-term prospective longitudinal study. We analyzed the correlation between noninvasively assessed stiffness parameters (pulse wave velocity [PWV], augmentation index [AIx], pulse pressure [PP], systolic area index, diastolic area index, diastolic reflection area), ankle-brachial index (ABI), and laboratory parameters (creatinine, glomerular filtration rate, urea, haemoglobin, C-reactive protein). Stiffness parameters were measured with a Tensiomed Arteriograph. These parameters were assessed before the transplantation, and 24 hours, and 1 and 2 weeks after surgery under standard conditions. We found that creatinine (P = .0008) and C-reactive protein (P = .006) serum levels decreased, and glomerular filtration rate increased significantly (P = .0005). We revealed that PWV (P = .0075) and AIx (P = .013) improved significantly. There was no significant change in ABI, PP, and the other monitored parameters. Along with the available data in the literature, our findings suggest that kidney transplantation has a positive effect on the arterial function.

Relationship between serum paraoxonase and homocysteine thiolactonase activity, adipokines, and asymmetric dimethyl arginine concentrations in renal transplant patients.

Paraoxonase lactonase activity protects against homocysteinylation; therefore, it can be a potential contributing factor to prevent atherosclerosis. We aimed to determine paraoxonase and HTLase activities and to clarify the relationship between HTLase activity and some cardiovascular risk factors, such as homocysteine, cystatin C asymmetric dimethylarginine (ADMA), and adipokines both in hemo dialyzed and transplanted patients. Among 114 hemodialyzed, 80 transplanted and 64 healthy control subjects, we investigated body mass index (BMI) as well as fasting serum contents of urea, uric acid, creatinine, cystatin C, homocysteine, glucose, lipids, total protein and albumin. Serum paraoxonase (PON 1) and HTLase activities were measured spectrophotometrically. ADMA, ADPN adiponectin, leptin (LEP) levels was determined with a sandwich enzyme-linked immunosorbent assay method. Dyslipidemic patients showed hypercholesterolemia, and high low-density lipoprotein (LDL); parallel with improved renal function, they displayed decreased cystatin C and homocysteine levels (P < .001). There was a significant negative correlation between PON 1 activity and cystatin C and homocysteine concentrations (P < .05). Obese patients revealed significantly higher LDL (P < .05) and leptin concentrations (P < .01). There was a significant positive correlation between PON 1 activity and adiponectin levels (P = .0276). Both dialyzed and transplanted patients displayed significantly lower HTLase activities compared to the control group (P < .001), particularly lower HTLase and PON 1 activities in dialyzed subjects compared with the transplanted group (P < .05). HTLase activity showed significant negative correlations with ADMA levels among the whole study population (P < .001), whereas positive associations were noted between PON 1 and HTLase activities (P < .001). HTLase activity may be a new predictor of cardiovascular risk in renal failure although it is modulated by other risk factors.

Prospective study of changes in arterial stiffness among kidney-transplanted patients.

BACKGROUND: Chronic kidney disease is one of the main risk factors for cardiovascular disease. Changes in stiffness parameters can predict the higher risk of the development of cardiovascular disease. METHODS: Cadaveric donor kidney transplant patients (n=184) were followed in a cross-sectional single-center study. Arterial stiffness parameters were measured by arteriography. We analyzed the correlation between stiffness parameters and immunosuppressive therapy, the main operation parameters, patient age, elapsed time since transplantation, carotid artery stenosis, and septual wall thickness. We enrolled 24 patients in a 3-year longitudinal study to analyze changes in stiffness parameters. RESULTS: Our cross-sectional study showed pulse wave velocity (PWV) to be significantly related to the age of the patient (P=.0001; r=0.41). There was no significant correlation between the stiffness parameters and type or dosage of immunosuppressive drugs and number of transplantations. We noted significant correlations between pulse pressure (PP) and pulse wave velocity (PWV), and augmentation index (AI) (P=.01). Patients with abnormal PWV (>12 m/s) showed significantly higher systolic blood pressures, body mass indexes, PP, and AI (P<.01). Our 3-year longitudinal study revealed a significant elevation in PWV. CONCLUSIONS: Improving endothelial function and prevention of atherosclerosis may help to reduce cardiovascular complications. Among chronic kidney disease patients, early transplantation is a possible way to prevent cardiovascular events. It is better to perform the transplantation at as early an age as possible.

Insertion/deletion polymorphism of the angiotensin-converting enzyme predicts left ventricular hypertrophy after renal transplantation.

BACKGROUND: Kidney transplant recipients show a higher risk for cardiovascular complications, such as left ventricular hypertrophy and heart failure, leading to the premature death in many cases. METHODS: We investigated the contribution of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism to the development of left ventricular hypertrophy (LVH), an indicator of heart disease progression among kidney transplant recipients. RESULTS: We observed a significant correlation between graft function and left ventricular mass index. The occurrence of LVH or severe LVH was significantly greater among patients with at least one D-allele (ID or DD). CONCLUSION: The use of ACE inhibitors or angiotensin receptor blockers seemed to be advantageous for patients with the ID and especially, the DD genotype.

Arterial stiffness in chronic renal failure and after renal transplantation.

Arterial stiffness is an independent cardiovascular risk factor, along with aging, hypertension, and cardiovascular disease. The augmentation index (AIx) and pulse wave velocity (PWV) are early markers of atherosclerotic vascular changes. Arteriography was used to determine systolic and diastolic blood pressure, pulse pressure (PP), AIx, and PWV in 82 male and 64 female renal transplant recipients (mean [SD] age, 45.3 [11.2] years). Cardiovascular risk was assessed using echocardiography and ultrasonography of the carotid arteries. The left ventricular wall thickness, ejection fraction, and stenosis of the carotid arteries were also measured. Fasting serum creatinine, cystatin C, homocysteine, C-reactive protein, immunoreactive parathyroid hormone, lipid, and calcium-phosphorus concentrations were determined. The serum cystatin concentration was 2.1 (0.2) mg/L, and the homocysteine concentration, 15.2 (2.6) micromol/L. After transplantation, body mass index, fat mass, and visceral fat area increased significantly (P < .01). The AIx was increased (AIx > or =10%) in 20% of men and 37% of women, PWV was increased (>10 m/s) in 43% of men and 34% of women, and PP was pathologically high (>12 m/s) in 10% of men and 12% of women. The PWV was significantly related to age (r = 0.52) and ventricular wall thickness (r = 0.46). Pulse pressure, BMI, and systolic and diastolic blood pressure correlated positively but modestly with PWV. There was a significant relationship between AIx80 and systolic (r = 0.42) and diastolic (r = 0.39) blood pressure and PP (r = 0.33). The ejection fraction correlated negatively with PWV and AIx. There was a strong association between carotid artery stenosis, PWV, and AIx80. All patients with PWV greater than 10 m/s demonstrated carotid artery stenosis. In conclusion, arteriography is an objective, noninvasive, and convenient method for early diagnosis and follow-up of atherosclerosis.

Insertion/Deletion polymorphism of Angiotensin-converting enzyme as a risk factor for chronic allograft nephropathy.

Angiotensin-converting enzyme (ACE) inhibitor therapy is widely used to treat chronic allograft nephropathy (CAN), which suggests a possible role of the renin-angiotensin system in the pathologic mechanism of the disease. The objective of this study was to investigate the possible link between CAN and ACE. The ACE insertion/deletion polymorphism and the amount and activity of ACE were determined in cadaver kidney recipients with CAN (n = 38) or normal renal function (n = 34). The DD genotype was observed significantly more frequently in the CAN group compared with the group with normal renal function. Moreover, the DD genotype was associated with a higher serum ACE concentration and greater serum ACE activity, compared with II genotype homozygotes. The insertion/deletion polymorphism of ACE affects ACE expression and activity in serum, and, therefore, may have an important role in the pathogenesis of CAN. These findings suggest that determination of the ACE genotype may be useful in identifying patients at high risk. In particular, the DD genotype may be considered an indication for ACE inhibitor therapy.

Renal artery aneurysm at the anastomosis after kidney transplantation.

Vascular complications represent serious problems after kidney transplantation. An aneurysm of the transplanted renal artery is an extremely rare but potentially devastating complication that which occurs in fewer than 1% of recipients. It can cause hypertension, functional impairment, and even graft loss. A 49-year-old man was admitted 6 months after his second renal transplantation. Duplex ultrasonography demonstrated an aneurysm at the anastomosis of the transplanted renal artery. The patient has not had any complaints. The function of the graft was stable. A computed tomography scan confirmed the diagnosis. Because of the high risk of rupture we decided upon surgical repair. During the operation, blood flow to the kidney was occluded; the graft was cooled with Euro-Collin's solution and ice-cold saline. After the resection there was enough usable arterial wall to construct a new anastomosis. The patient had an uneventful postoperative period, the serum creatinine decreased to the preoperative level, and the function of the graft was stable. Renal artery aneurysms represent high-risk complications. We decided on surgical repair, which was performed with simultaneous perfusion and cooling of the graft. There are only a few similar cases in the literature; it was the first operation using this method in our practice. Surgical reconstruction of a renal artery aneurysm, if feasible, is a safe procedure that prevents aneurysm rupture and saves the graft.

[Acute pancreatitis after kidney transplantation]. / Vesetranszplantált betegek akut hasnyálmirigy-gyulladása.

UNLABELLED: Pancreatitis following kidney transplantation was first described by Starzl in 1964 [19]. The incidence rate of the disease involving severe complications ranges from 1.2 to 6.8%. The number of risk factors, besides those of the normal population, is increased by a number of other factors, i.e. uremia, disorder of lipid metabolism, polycystic kidney, immunosuppressive drugs, cytomegalovirus infection, etc. The mortality of acute pancreatitis in a kidney transplant patient is, in spite of treatment with the most up-to-date methods, is much higher (53-60%) than that for a non-transplant patient. In the period between 27 June 1991 and 31 December 2000 the number of cadaver kidney transplants performed in the Transplantation Division of the 1st Department of Surgery of the Medical and Health-Science Centre of the University of Debrecen was 349. During this period 9 incidences of acute pancreatitis were found in 8 patients. The frequency of incidence was 2.56%. In the present communication we analyse the prognosis of 9 kidney transplant patients, with special respect to immunosuppression. RISK FACTORS: One patient was administered Cyclosporin alone, four were given Cyclosporin and Steroids, a further one Cyclosporin, Steroids and Azathioprine, the remaining three were treated with Cyclosporin, steroids and Mycophenolate Mophetil. In six cases out of nine multiorgan insufficiency (kidney, lung, liver) was encountered on presentation, three cases were accompanied by peritonitis. In spite of early jejunal nutrition, intensive therapy, antibiotic treatment, CT monitoring, if needed, necrectomy and oncotomy, three of our patients died from multiorgan insufficiency induced by septico-toxic state (mortality 33.3%). Other six patients recovered. CONCLUSIONS: The mortality rate of acute pancreatitis is much higher in immunosuppressed patients. The role of the etiological factors is not unequivocal in the development of pancreatitis. Nevertheless, all possible risk factors have to be taken into consideration when starting the immunosuppressive treatment of transplant patients and during their follow-up. By optimally adjusting the immunosuppressants we can decrease the risk of pancreatitis, however, the prognosis of the diseases, in agreement with the data in the literature, cannot be considerably improved even with the most up-to-date methods.

Interrater reliability of the active-knee-extension test for hamstring length in school-aged children.

PURPOSE: The purpose of this study was to determine the interrater reliability of the active knee-extension test (AKET) using a stabilizing apparatus to measure hamstring length. METHODS: One hundred one subjects (53 girls, 48 boys) ranging in age from 10 to 13 years with no known neuromuscular problems participated. The AKET was performed with subjects lying supine with the hip flexed to 90 degrees with a stabilization device attached to a plinth. Next, subjects were instructed to actively extend the knee until the rater detected myoclonus. Then, the rater flexed the knee until myoclonus subsided and the knee angle was measured with a blinded goniometer. This procedure was repeated by each of three raters. RESULTS: Data were analyzed using ICC (2,1) demonstrating good interrater reliability of 0.79. CONCLUSION: Our results suggest that the AKET, when used with the stabilizing apparatus, demonstrates good interrater reliability for children aged 10 to 13 years.