Cytotoxic Antibody Detection by Means of Flow-Cytometric Cross-Match.

BACKGROUND: Complement-dependent lymphocytotoxicity (CDC-XM) and flow-cytometric (FCXM) cross-match are analyzed individually for each donor and recipient pair, because these techniques have fundamental differences for the evaluation of histocompatibility. Lately, cytotoxic flow-cytometric cross-match (cFCXM) has been developed as an alternative to both CDC-XM and FCXM techniques. We evaluated the limits of cFCXM with the use of different positive serum dilutions. METHODS: CDC-XM, FCXM, and cFCXM tests were performed with the use of commercially available negative and positive serum samples and lymphocytes from healthy donors. RESULTS: Complement-dependent cell death was successfully detected with the use of cFCXM. Complement-dependent cell death ratios in cFCXM were similar those in CDC-XM. With cFCXM, not only complement-dependent cell death but also IgG binding could be detected within a single assay. At higher concentrations of the positive serum, IgG-fluorescein isothiocyanate (FITC) mean fluorescent intensity (MFI) values detected with the use of cFCXM were less than those of conventional FCXM. Correspondingly, for dead cells, MFI values of IgG-FITC were less than those of live cells in higher positive serum concentrations in the cFCXM assay. Moreover, our results demonstrated that in cFCXM analysis, the decreasing ratio of dead cells at increasing positive serum dilutions was not in parallel with the same decrease in IgG-FITC MFI values. CONCLUSIONS: The cFCXM technique detects complement-mediated cytotoxic cell death with the additional ability to show IgG binding in the same tube and therefore may reduce the necessary bench time and workload.

Relationship of Urothelial Gene Expressions in Urine-Deprived Bladders of Renal Recipients With Posttransplant Urinary Infections.

OBJECTIVE: In this study, we analyzed gene expression levels of apoptotic (Fas, FasL, Bcl-2, Bax) and survival (CXCR1, CXCR2, IL-8) signal pathways of the urine-deprived bladder tissues and the relation of urinary tract infections with these pathways. MATERIAL AND METHODS: We included 37 patients admitted for renal transplantation between December 2009 and December 2012. Bladder mucosal samples were obtained at the time of transplantation and 6-8 weeks posttransplantation, at the time of ureteral catheter removal. RNA extraction and cDNA synthesis were done using guanidium-thiocyanate and colon filter methods. Expression analysis was studied with quantitative real-time polymerase chain reaction optimized with ROX dye and internal control ß-actin. RESULTS: According to our findings Fas, FasL, Bcl-2, and Bax expression was higher in urine-deprived bladder samples than those in the posttransplant samples (P < .05). Although Fas, FasL, Bcl-2, and Bax expression levels increased in pretransplant samples, there was an increase in posttransplant bladder samples; however, this increase was not as marked as those of pretransplant samples. IL-8, CXCR1, and CXCR2 expression was decreased at the pretransplant samples and increased in posttransplant bladder samples. CONCLUSIONS: We have found an upregulated apoptotic process and decreased survival signals at the urine-deprived bladder tissue. After transplantation, bladder tissue survival parameters were increased, demonstrating the importance of urinary flow for bladder tissue.

Effects of Urethral Stricture on Allografts in Kidney Transplantation.

BACKGROUND: Iatrogenic urethral stricture after renal transplantation is mostly seen after urethral manipulations. Early diagnosis and treatment are crucial for the safe continuity of the graft functions. In this study, the effect of urethral strictures on graft functions during the post-transplantation period was investigated. METHODS: A total of 477 kidney transplantations were carried out from both live and cadaveric donors in our center from 2004 to 2014. Thirty-two patients who had insufficient data were excluded from the study. All the patients' urine cultures were negative before the surgery, and antibiotic prophylaxis were applied to all. Urethral catheters were taken out 4-7 days after transplantation. Double-J catheters were removed 6 weeks later. Internal urethrotomy and open urethroplasty surgeries were done for the patients who had urethral stricture. The results of creatinine, post-micturitional residual urine (PMR), International Prostate Symptom Score (IPSS), and uroflow examinations were evaluated. RESULTS: Average preoperative creatinine and postoperative creatinine values were, respectively, 1.74 ± 0.65 mg/dL (range, 0.83-3.03) and 1.24 ± 0.57 mg/dL (range, 0.9-2.24). A meaningful improvement was observed in terms of preoperative and postoperative IPSS values. A significant difference was seen between preoperative and 6th-month postoperative PMR values: 192.6 ± 57.2 mL and 36.7 ± 17.4 mL, respectively. CONCLUSIONS: Urethral strictures in transplant patients may arise due to many factors, such as repetitive urethral catheterization and inflammation. Early diagnosis helps to have better results for the treatment of the kidney functions.

Cancer Screening of Renal Transplant Patients Undergoing Long-Term Immunosuppressive Therapy.

OBJECTIVE: With this study we aimed to research the effects of immunosuppressive drugs, their cumulative doses, and viral infections on development of malign tumors in patients who have undergone treatment for 5 years. METHODS: We examined 100 patients who underwent renal transplantation from 2004 to 2009. Patients had mycophenolate mofetil and steroid in addition to cyclosporine, sirolimus, or tacrolimus as immunosuppressive treatment. For malignancy screening, physical examination, radiologic and endoscopic screening were done, and immunosuppressive drugs and their cumulative doses, age, sex, body mass index (BMI), dialysis history, and viral infection history were investigated. RESULTS: The mean age of patients was 42.03 ± 11.30 years. There were 1 colon cancer patient, 1 retroperitoneal liposarcoma, 1 renal oncocytoma, 3 Kaposi sarcoma patients treated with cyclosporine; in those treated with Tac there were 1 basal cell carcinoma, 1 Kaposi sarcoma, 2 thyroid carcinoma, 1 breast carcinoma, 1 bladder carcinoma, 1 renal cell carcinoma, and 1 colon carcinoma patients. The mean age of patients having carcinoma was statistically significant compared with those without cancer (P < .01). The prednisolone cumulative dose was significantly higher in carcinoma patients than in patients without carcinoma (P < .01). RESULTS: The use of long-term chronic immunosuppressive therapy may increase the development of cancer. The risk of carcinoma increases with increasing drug dose and time period of the immunosuppressive drug. There was not a negative effect on cancer prevalence in patients with cyclosporine or tacrolimus. But the cumulative dose of steroids significantly increased malignancy occurence.

Monitoring of CD3(+) T-cell count in patients receiving antithymocyte globulin induction after cadaveric renal transplantation.

AIM: Although antithymocyte globulin (ATG) has been used for years, its ideal dose and administration period is obscure. Herein, we sought to use the CD3(+) cell count to detect the optimal ATG dosage. MATERIAL AND METHODS: Twenty-one patients who underwent cadaveric donor renal transplantation from January 2009 to January 2012 received a 1 mg/kg ATG initial dose at the time of the operation. Patients were randomized into 2 cohorts. Group 1 (n = 11) received ATG according to the clinical and total lymphocyte count and group 2 (n = 10), the dose was tailored according to the CD3(+) cell count. We compared the total and daily ATG dosages, ATG administration period, side effects of ATG, the number of days to a serum creatinine level <2 mg/dL, graft function at 3 months, acute rejection episodes, infection rates, costs of CD3(+) analysis, and ATG amounts. RESULTS: Both groups showed similar gender, age, and human leukocyte antigen matching data. There was no difference in presensitizing events or panel-reactive antibody class 1 and 2 levels. The number of days to a serum creatinine level of <2 mg/dL was 11 ± 1.5 for group 1 versus 10.4 ± 0.8 for group 2 (P = .45). Between groups 1 and 2, there was a significant difference between the mean total (P = .031) and mean daily ATG dosages (P = .006). We used a total dose of 3800 mg ATG for group 1 and 2200 mg for group 2 and for the group 2 who underwent 43 CD3(+) cell counts. The expenditure per patient was 20% higher among group 1 than group 2. CONCLUSION: Determination of appropriate ATG dosages by CD3(+) cell counts was useful, reliable, and cost effective.

Avoiding abdominal flank bulge after lumbotomy incision: cadaveric study and ultrasonographic investigation.

OBJECTIVE: The object of this study was to better define the relevant anatomy and innervation of the anterolateral abdominal wall musculature seeking to avoid abdominal wall complication after open donor nephrectomy. We dissected four cadavers and retrospectively assessed donor ultrasonographic imaging of anterolateral abdominal muscle atrophy after donor nephrectomy with a lumbotomy incision. METHODS: Anatomic study was performed on four cadavers using bilateral dissections. The 8th, 9th, 10th, 11th, and 12th (subcostal) intercostal nerves were dissected from the intercostal space to the rectus sheath. With the experience gained from anatomic study, we performed 40 living donor incisions 1.5 to 2 cm medial to the tip of 12th rib, toward the lateral border of the rectus muscle and the umbilicus. Donors were invited to the hospital at 1 year postoperative to examine abdominal wall complications. Ultrasonography (USG) was performed to assess the thickness of the abdominal wall muscles bilaterally to ascertain whether there was atrophy. RESULTS: All distal intercostal nerves ran as multiple mixed segmental nerves, communicating with each other widely within the neurovascular plane. The thick 12th nerve was located at 1.5 to 2 cm medial and under the tip of the 12th rib, running to the suprapubic area. Postoperative USG confirmed that the mean percent thickness of the abdominal muscles of the operative side was not significantly different from the other side (P < .05). CONCLUSION: Most significant intercostal nerve contributions to the anterolateral abdominal wall arise from T12. Damage to the intercostal nerves will be minimal if the lombotomy incision is performed above the safe line between the tip of the 12th rib and the umbilicus.

Serum flow cytometric C1q binding antibody analysis of renal recipients with low levels of sensitization.

AIM: Patients displaying flow cytometric crossmatch results within the grey zone of positivity are hard to evaluate, especially if they are undergoing their first transplantation. For these patients assays of donor-specific anti-HLA (human leukocyte antigen) antibodies with complement-fixing properties to cause cell lysis are important for antibody-mediated rejection and graft failure. The aim of this study was to detect the relevance of serum C1q-binding antibodies detected in renal recipients with grey zone crossmatch reactivity who were considered to show low levels of sensitization against their potential donors. METHOD: This study includes 114 patients who were admitted for their first renal transplantation between September 2009 and August 2011, including 33 subjects considered by flow cytometric cross-match to be the sensitized group, whereas the remaining 81 recipients had negative results. We analyzed the accumulation of serum the immunoglobulin (Ig)G bound C1q on HLA-coated flow cytometric panel reactive antibody (FlowPRA) beads. The serum samples were retrospectively analyzed with [C1q]FlowPRA (HLA class I and II), which were collected during the pretransplantation period every 6 months and every week posttransplantation within the first month and every 3 months thereafter. All serum samples were analyzed for the presence of anti-FlowPRA IgG alloantibody. We compared the C1q FlowPRA-positive and-negative groups for the number of posttransplantation days that the serum creatinine level was below <2 mg/dL as a metric of graft function. RESULTS: With a mean follow-up of 492 ± 84 days, there was a significant difference between flow cytometric crossmatch results and creatinine decrease rate (P = .02). The serum creatinine decrease rates of the 9 C1q-positive versus the 15 C1q-negative subjects showed significant difference (P < .05). CONCLUSION: C1q-binding antibody analysis shows the presence of serum antibodies capable of complement binding and antibody-mediated rejection, which could be useful to assess rejection risk among the "grey zone" of renal recipients with low levels of sensitization against their donors.

The impact of C4d staining as a humoral injury marker.

PURPOSE: Acute and chronic humoral injuries in renal transplant recipients are the main reasons for graft rejection and failure. Histological and clinical characteristics of humoral rejection and symptoms are variable and not always helpful for differential diagnosis. Clinical monitoring of the allograft, an elevated serum panel-reactive antibody (PRA), and the presence of donor-specific antibody (DSA) during immune monitoring as well as C4d staining of biopsy material can establish the differential diagnosis. Even without a cellular component, humoral rejection reaction is serious because the target tissue is the graft endothelium. Because the kidney graft has a rich vascular structure this attack causes permanent injury to the kidney in the long term. Graft dysfunction in this setting is usually more severe, requiring dialysis therapy, compared with acute cellular reactions. Positive C4d staining of peritubular capillaries in biopsy material represent a hallmark of complement-dependent cytotoxicity, supporting the diagnosis of humoral rejection. We analyzed C4d staining as a hallmark of humoral rejection. METHODS: From 2009 to 2011, we analyzed the relationship between pathological findings of C4d immunohistochemistry staining and the clinical outcomes of 45 kidney transplant recipients who underwent a kidney biopsy because of graft dysfunction due to possible humoral rejection. RESULTS: Biopsy specimens of 15 patients stained C4d positive; the remaining 30 showed negative results. Intravenous steroids, PP + IVIG with or without antithymocyte globulin (ATG), was administered for treatment. Sixty six percent (n = 10) of patients were C4d positive with 16% (n = 5) of those showing C4d-negative biopsy results, losing their grafts, and returning to hemodialysis. CONCLUSIONS: C4d staining refractory humoral rejection injury was related to poor graft outcomes.

Flow cytometric detection of anti-AB antibody titers in blood group O recipients of blood group A2 donor kidneys.

AIM: ABO-incompatible kidney transplantation has been accepted for end-stage renal failure patients who have no ready opportunity for a deceased or living donor. Antibody titration for ABO-incompatible renal transplantation is not only difficult but also lacks conformity among laboratories. Herein we analyzed 20 living related renal transplant couples to detect recipient anti-A2 antibody using flow cytometric analysis. MATERIALS AND METHODS: Patients were admitted to our center for renal transplantation between January 1999 and December 2010. All but four of them had undergone a previous renal transplantation from an ABO-compatible donor but experienced graft failure. All donor blood groups were subtyped by our blood bank using a lectin-based dilution assay. To detect recipient anti-A2 antibody titers we used a tube hemagglutination method. A/B antibody titer analysis by flow cytometry incubated serially diluted serum samples with donor erythrocytes. Each analysis was repeated three times over a 2-week period using an older and the last sera simultaneously. RESULTS: The 13 male and 7 female patients showed our overall mean age of 32 ± 12 years. All patients had panel-reactive antibody levels below 15%. The level of flow cytometric antibody titers did not vary upon repeated analysis (P = .01). When compared with the tube method there was a discrepancy of the level at which the antibody titer became negative. DISCUSSION: Flow cytometric antibody titration is a practical and rapid technique to determine the amount of anti-A2 antibody in renal recipients.

Risk factors for osteoporosis after renal transplantation and effect of vitamin D receptor Bsm I polymorphism.

OBJECTIVE: Rapid loss of vertebral or hip mineral density after renal transplantation is a major complication which occurs within 6-12 months. The aim of this study was to evaluate risk factors contributing to bone disease in the early stage after renal transplantation and the effect of vitamin D receptor (VDR) gene polymorphisms. METHODS: We prospectively followed for up to 12 months 44 patients (29 men and 15 women) with end-stage renal disease who underwent kidney transplantation. All patients received prednisone with either cyclosporine (CsA)/mycophenolate mofetil (MMF) or tacrolimus (Tac)/MMF therapy. Spine, hip, and whole body bone mineral density (BMD) was measured at 12 months after transplantation. According to World Health Organization recommendations, our patients were categorized as normal, osteopenic, or osteoporotic BMD levels. VDR alleles were genotyped as BB, Bb, or bb by polymerase chain reactions based on polymorphism at the Bsm I restriction site. RESULTS: Forty-six percent of patients were normal, 43% osteopenic, and 11% osteoporotic. Significant risk factors for osteoporosis among renal transplant recipients were younger age and pretransplant high intact parathyroid hormone (iPTH) levels. (P values .045 and .027, respectively). According to polymorphic group categorization, posttransplant serum Ca was significantly higher in patients with BB or Bb genotype than in those with bb genotype (P = .012). Although there was no statistical significance regarding iPTH levels, it was higher among Bb+BB than the bb genotype group. Also, first-year BMD analysis after transplantation according to Bsm I polymorphism showed significant differences in femur BMD levels according to the dual classification of polymorphism (P < .05). The BMD levels in the bb group was higher than in the Bb+BB group. CONCLUSIONS: Although high pretransplant iPTH levels and younger age enhanced posttransplant bone loss, functionally different alleles of the VDR gene may modulate bone turnover during the first year after renal transplantation.

Dermatologic findings in renal transplant recipients: Possible effects of immunosuppression regimen and p53 mutations.

OBJECTIVE: To analyze the dermatologic lesions and possible effects of immunosuppression treatment and p53 gene mutations on dermatologic findings in renal transplant recipients. MATERIALS AND METHODS: The study included 163 renal transplant recipients. After dermatologic examination, cultures, and histopathologic and genetic analyses were performed. A single-strand conformation polymorphism technique was used to analyze p53 gene mutations. Patients were categorized into 3 groups according to time since the transplantation procedure. Results were analyzed using the χ(2) test, using a software program (SPSS version 13.0; SPSS, Inc, Chicago, Illinois). RESULTS: Mean (SD) age of the 163 transplant recipients (65 women and 98 men) was 40 (11) years, and posttransplantation follow-up was 65 (55) months. The most frequently observed drug-related lesion was hypertrichosis, in 46 of 150 patients. Of 115 lesions, the most commonly observed were verruca vulgaris (n = 34) from viruses, and pityriasis versicolor (n = 21) from superficial fungal infections. Of the total group, 20 patients (12.2%) were mutation carriers. Compared with the entire cohort, the group with premalignant lesions demonstrated more p53 mutations (11% vs 50%; P = .004). Patients given cyclosporine therapy exhibited more premalignant or malignant cutaneous lesions compared with patients who received other agents (P = .03). CONCLUSION: Patients carrying p53 mutations developed a malignant lesion in the late posttransplantation period, which suggests the importance of prediction of risk.

Effects of cyclosporine-tacrolimus switching in posttransplantation hyperlipidemia on high-density lipoprotein 2/3, lipoprotein a1/b, and other lipid parameters.

OBJECTIVE: In renal transplant recipients, cyclosporine treatment appears to cause more frequent hyperlipidemia than tacrolimus usage. In this study, hyperlipidemic renal transplant recipients who use cyclosporine were investigated for changes in high-density lipoprotein (HDL)-2/3, apolipoprotein (Apo) A1/B, other lipid and biochemical parameters, and body mass index after prospective cyclosporine to tacrolimus switching. MATERIALS AND METHODS: Fifteen patients, including 9 females of overall mean age of 33.2 +/- 10.7 years and posttransplantation time of 78.06 +/- 42.93 months with a mean body mass index of 23.77 +/- 3.34 kg/m(2), were included if they were nondiabetic, hyperlipidemic, and had undergone renal transplantation between 1992 and 2000, using cyclosporine and candidates for a switch to tacrolimus due to hyperlipidemia. Before switching to tacrolimus and at 12 months of tacrolimus use we studied fasting blood samples for creatinine, uric acid, glucose, triglyceride, Apo A1, Apo B, low-density lipoprotein (LDL), HDL2, HDL3, and total cholesterol. RESULTS: There were no significant differences in creatinine, uric acid, glucose levels, or body mass index before tacrolimus versus 12 months thereafter. It was observed that tacrolimus significantly decreased triglyceride, Apo A1, Apo B, LDL, HDL, and total cholesterol levels (P < .001; P = .006; P = .01; P < .001; P = .03; P .05). CONCLUSION: Switching from cyclosporine to tacrolimus was associated with a more favorable cardiovascular risk profile by improving hyperlipidemia.

The clinical significance of parathyroid tissue calcium sensing receptor gene polymorphisms and expression levels in end-stage renal disease patients.

BACKGROUND: The calcium sending receptor (CaSR) allows parathyroid and kidney tubular cells to regulate PTH secretion and tubular calcium reabsorption. In the present report, we examined the relationship between CaSR gene polymorphisms and parathyroid CaSR expression and serum calcium/parathyroid hormone (PTH) levels and clinical progress in ESRD patients in the Turkish population. METHODS: We genotyped the CaSR R990G and Q1011E variants in 192 end-stage renal disease (ESRD) patients by allele-specific PCR. CaSR expression in parathyroid tissues of operated 33 patients was quantified with quantitative reverse transcription-PCR. RESULTS: Compared with other genotypes, the ratio of both codon 990-AA and 1011-CC polymorphisms was found higher in operated patients (p = 0.001). In the total patient group PTH levels were found higher in patients with CC1011 genotype than those with CG1011 (1015.15 +/- 925.41 pg/ml; 523.84 +/- 544.6 pg/ml, respectively, p = 0.002). There were statistically important higher Ca2+ levels in the AA990 allele carrying cases than AG990 positive ones (9.3 +/- 1.0 mg/dl vs. 8.8 +/- 0.9, p = 0.006). On the other hand, the expression of CaSR in parathyroid tissue was found inversely proportional with serum PTH level (r = -0.71). CONCLUSION: Present data suggest that co-presence of CaSR gene AA990 and CC1011 alleles is a possible risk factor for bad prognosis in secondary hyperparathyroidism. Patients carrying this genotype have tendency to require operation early in their medical therapy period and need postoperative close follow up for possible recurrences.

Pediatric renal transplantation: Clinical analysis of 28 cases.

We performed an outcome analysis of 28 pediatric renal transplant recipients whose mean age at transplantation was 15.2 +/- 2 years (range: 11 to 17 years) and the M/F ratio, 0.75. Four patients received cadaveric grafts. One patient needed retransplantation due to primary nonfunction. Mean HLA match was 3.6 (range: 3 to 5). Immunosuppression was cyclosporine (n = 13) or tacrolimus (n = 11) or sirolimus (n = 4), as well as steroids and azathioprine or mycophenolate mofetil. Delayed graft function occurred in four patients. The main complications were arterial hypertension (n = 11), anemia (n = 4), urinary tract infection (n = 10), hypercholesterolemia (n = 7), and cytomegalovirus infection (n = 1). An acute rejection episode (ARE) occurred in four patients. ARE and hypertension rates were similar between the immunosuppressive drug groups. All the patients with graft failure were on cyclosporine (P = .03). Hemodialysis and peritoneal dialysis (median duration: 6 months) were performed preoperatively in 25 and 3 patients, respectively. The length of pretransplant dialysis was longer among patients with graft failure (P > .05). Noncompliance (10.7%) resulted in an ARE in one patient and graft loss in two patients. One patient died with a functioning graft. Primary disease recurred in one patient. The median follow-up period was 44 months (range: 6 to 157 months). Mean serum creatinine level was 1.35 +/- 0.74 mg/dL at the last follow-up. One- and 3-year graft survival rates were 92% and 86%, respectively, and patient survival was 100%, each. Seventeen patients (60.7%) continued their education after the transplantation; six started working. Successful transplantation in the pediatric age group together with intensive rehabilitation posttransplantation are important to make these children productive individuals to the society.

Kaposi's sarcoma in renal transplant patients: predisposing factors and prognosis.

Among 772 kidney transplant recipients in two centers 25 patients developed Kaposi's sarcoma (KS) (3.2%). The twenty-two of 25 recipients with regular follow-up records were compared for predisposing factors with another group of 22 renal transplant recipients. All patients received cyclosporine (CsA), azathioprine, or mycophenolate mofetil and steroids; patients who received cadaver donor organs additionally received antilymphocyte globulin for induction. KS was diagnosed at a mean of 25.8 months after transplantation. The male to female ratio; mean age; mean follow-up period; hepatitis B, hepatitis C, cytomegalovirus status; and other infection rates were similar in the two groups. Some HLA-DR antigens were detected only in patients with KS. All patients had mucocutaneous involvement, which was multiple in 54.5%. Visceral involvement, and lymph node involvement, or both was detected in seven patients. First-line treatment was to stop CsA and reduce the doses of the other drugs. Three patients underwent additional surgical excision. Fourteen (63.6%) patients experienced complete remissions, including six who required additional chemotherapy or radiotherapy after incomplete or lack of responses to first-line treatment. Two patients died with functioning grafts due to generalized KS. Seven patients returned to hemodialysis at a mean of 36 months after the diagnosis of KS. No significant predisposing factor was observed other than the prevalence of specific HLA-DR antigens. Chemotherapy or radiotherapy should be initiated for patients with multiple, diffuse, and rapidly progressive lesions or organ dysfunction in addition to withdrawal of CsA and tapering of other drugs. Generalized KS displays the poorest prognosis.

Blood pressure and graft outcome in renal transplantation.

To investigate the effects of blood pressure (BP) on kidney function, we reviewed 116 patients who had a median follow-up of 40.5 months. Systolic and diastolic hypertension (HTN) at month 6 resulted in significantly higher serum creatinine (SCr) levels at 1 year, compared with patients with normal BP, namely, 2.2 versus 1.4 mg/dL (P = .0001) and 1.87 versus 1.5 mg/dL (P = .04), respectively. Mean systolic and diastolic BP at the end of 1 and 6 months were significantly higher among patients who had returned to hemodialysis or who had an SCr > or =2 mg/dL at their last follow-up. Mean age, mean donor age, donor type, and sex had no significant effect on graft function. Patients receiving Rapamune-based treatment (n = 9) had no graft failure; graft outcomes were similar between cyclosporine-based and tacrolimus-based immunosuppression therapy. Patients with biopsy-proved acute rejection showed significantly lower graft survival. By multivariate analysis, systolic HTN at the end of 1 month (P = .006) and 6 months (P = .01), and diastolic HTN at the end of 6 months (P = .04) were independent risk factors for graft outcome. Actuarial 5-year graft survival was 95%, versus 76% in patients with normal BP versus systolic HTN at 1 month, respectively (P = .02). A significant difference in 5-year graft survival was observed between patients with normal diastolic BP and diastolic HTN at 6 months (95% versus 67%, respectively; P = .001). Since systolic and diastolic BP at different times before and after transplantation correlate with graft function, more attention should be paid to maintain normal BP in patients with renal transplants.

A venous ""patch"" technique improves patency rate of primary radiocephalic fistulas.

A retrospective study was designed to evaluate the outcome of native wrist arteriovenous fistula (AVF) constructed with standard versus venous ""patch"" techniques in terms of immediate, early and late failures. Between January 1991 and July 2001, 1948 patients underwent primary wrist radiocephalic AVF. Thirty eight per cent (740) of the fistulas were created using the venous patch technique. Immediate and/or early failure rate was significantly lower in the venous ""patch"" technique (Group II) compared to the standard technique (Group I). Although the difference in late failures between Groups I and II did not reach statistical significance, the cumulative patency rates were significantly better in Group II. Radiocephalic fistula constructed with the use of venous patch is recommended whenever the anatomy is feasible.

Gluteus maximus flap for persistent fecal fistula following rectal resection via the posterior approach.

An alternative technique for the treatment of persistent anastomotic leak following resection of the rectum via combined celiotomy and posterior approach is described. Lower aspect of the gluteus muscle is advanced and sutured to cover the anastomotic gap.