Response to treatment in kidney transplant recipients with acute antibody-mediated rejection: A follow-up biopsy study
.

BACKGROUND: The aim of this study is to evaluate the efficacy of a treatment protocol for the management of acute antibody-mediated rejection (AAMR) and mixed-type rejection (MTR), both histopathologically and clinically. MATERIALS AND METHODS: Of the 362 cases undergoing kidney transplantation from January 2010 to January 2018, patients with AAMR or MTR in the first 3 months after transplantation were included. All patients had follow-up biopsy (Bx) after treatment. RESULTS: 33 (9.1%) patients had diagnosis of AMR. Mean follow-up was 35 ± 20 months. 28.5% of patients had poor clinical progression at the last follow-up. Of the 25 patients with functional grafts, the mean serum creatinine was 1.6 ± 0.6 mg/dL for live and 2.1 ± 1.0 mg/dL for deceased transplant recipients. In diagnostic biopsies, there were 61% MTR. In follow-up Bx, after treatment, both C4d positivity and the severity of rejection had decreased while the mean chronic allograft damage index (CADI) score and transplant glomerulopathy showed an increase. CONCLUSION: With effective antibody mediated rejection (AMR) therapy, renal function parameters were significantly improved. Histologically, improvement in tubulointerstitial inflammation may be responsible for this process. However, progressive chronic changes, particularly in the glomeruli, are noteworthy.

Simple renal cysts in the solitary kidney: Are they innocent in adult patients?

In patients with a solitary kidney; residual renal volume is an important prognostic factor for kidney survival. At present, the impact of renal cysts on solitary kidney survival is not clear. The aim of this study is to examine the association of cysts on progression of renal failure in patients with a solitary kidney. METHODS: This study included sixtyfive solitary kidney patients. The remaining kidneys after indication nephrectomy (IN) were evaluated with urinary system ultrasound. The primary outcome of the study is the progression of kidney failure during follow-up which was defined as: 25% decrease in glomerular filtration rate (GFR) and / or the need for renal replacement therapy (RRT). RESULTS: The mean age of the patients was 55 ± 14 years and mean follow-up was 53 ± 27 months. Renal cysts were present in 30.7% of patients. 33.8 percent of patients had kidney disease progression and 10.7 % required RRT. Those with progressive disease were older (61 ± 13, 52 ± 14; P = 0.011), had lower baseline GFR (30 ± 11, 39 ± 18; P = 0.035), higher proteiuria (2.84 ± 0.58, 2.47 ± 0.57; P = 0.031) and frequently harboring cysts in the solitary kidney (52.3%, 20.4%; P = 0.006). Progression to kidney failure and RRT requirement in cases with or without renal cysts was (60% vs. 22%; P = 0.004) and (20% vs. 6.6%; P = 0.123), respectively. Acquired cysts in solitary kidney was independently associated with progression to kidney failure and RRT respectively (Exp(B) 3.173; P = 0.01 and Exp(B) 12.35; P = 0.04). CONCLUSION: Simple renal cysts in solitary kidney patients with impaired renal function is associated with poor renal outcome. Large-scale studies are needed to clarify this issue.

Immune profile of asplenic patients following single or double vaccine administration: A longitudinal cross-sectional study.

OBJECTIVE: Splenectomy poses a lifelong threat for the development of uncontrolled sepsis despite vaccination. As it is impractical to measure the levels of each antibody against 23 most frequent bacterial serotypes, different surrogate markers of immune response should be identified. MATERIAL AND METHODS: Forty-eight patients with benign disorders were vaccinated with Pneumo-23 and Act-HIB before or at the day of surgery. The immunological response and opsonization capacity of the patients after splenectomy was analyzed through the quantitative measurement of IgG, IgM, C3, and C4 titers; flow-cytometric analysis of (CD3+) T-lymphocytes and (CD19+) B-lymphocytes; and isolation of CD27+ B cells by immunomagnetic positive selection. Blood samples were drawn at the sixth month and 5 and 7 years after surgery. RESULTS: The mean follow-up period was 98.4 months. All the patients in this series had normal IgG, C3, C4 levels and a normal distribution of CD19+ B-cells and CD8+ T-cells in three follow-up periods. Moreover, C3 levels markedly improved to 133.5±37.3 mg/dL at 5 years and remained stable thereafter. CD19+ B-lymphocyte values have progressively improved to the normal range in 98% patients at 7 years. Further, low levels of CD27+ B-cell population (memory cells) was observed in only 12.5% patients at the last follow-up. Adequate seroconversion of IgG, IgM with normal C3, C4, and CD19+ B-cell levels were accomplished in almost all patients. Early postoperative death and late overwhelming infections did not occur. CONCLUSION: Our results are indicative of the resumption of the immune function following Pneumo-23 and Act-HIB administrations, instigated by the probable activation of B cells and adequate production of C3, C4, IgG, and IgM antibodies in remote lymphoid tissues.

Adjuvant versus neoadjuvant chemoradiotherapy in distal rectal cancer: Comparison of two decades in a single center.

OBJECTIVE: Standard surgery alone was not able to decrease local recurrence (LR) rate below 20% in rectal cancer treatment. Thus, many centers administered neoadjuvant radiotherapy (preopRTx) with or without concomitant chemotherapy for the prevention of LR. In this study, the results of 164 consecutive patients with mid- and distal rectal cancer who received surgery and adjuvant chemoradiotherapy (Group A) or neoadjuvant chemoradiotherapy (Group NA) followed by surgery are presented. MATERIAL AND METHODS: The staging system used in this study is that of the American Joint Committee on Cancer (AJCC), also known as the TNM system. Eligible patients were required to have radiologically assessed stage 1 (only T2N0M0) to stage 3C (T4bN1-2M0) tumor with pathologically confirmed R0 resection. The surgical method was total mesorectal excision (TME). Radiotherapy was applied with daily 180 cGy fractions for 28 consecutive days. Chemo-therapy comprised 5-fluorouracil (450 mg/m(2)/d) and leucovorin (20 mg/m(2)/d) bolus at days 1-5 and 29-33. RESULTS: Nine patients (13%) in Group NA achieved pathologic complete response (pCR). In Group NA and Group A, locoregional recurrence (LRR) rates were 6.7% and 30.8%, (p<0.001), the mean LR-free survival was 190.0±7.3 months and 148.0±11.7 months (p=0.002) and the mean overall survival (OS) was 119.2±15.3 months and 103.0±9.4 months (p=0.23), respectively. A significant difference with regard to LR has been obtained with a statistical power of 0.92. Secondary outcome measures (DFS and OS) have not been met. CONCLUSION: Neoadjuvant chemoradiotherapy with TME is an efficient treatment protocol, particularly for the treatment of magnetic resonance imaging-staged 2A to 3C patients with two or three distal rectal adenocarcinomas. Given that a considerable proportion of patients with cT2N0M0 would develop pCR, this method of treatment can be considered for further studies.

Splanchnic vein thrombosis following renal transplantation: a case report.

BACKGROUND: Recurrent episodes of venous thrombosis have been closely correlated with JAK2 V617F mutation. Upto date, JAK2 gene mutation has not been defined as a prothrombic risk factor in renal transplant recipients. Herein; we present a case of portosplenic vein thrombosis in a primary renal transplant recipient with JAK2 V617F mutation who had no history of prior venous thromboembolism or thrombophilia. CASE PRESENTATION: A 59 year old female caucasian patient with primary kidney transplant admitted with vague abdominal pain at left upper quadrant. Abdominal doppler ultrasound and magnetic resonance imaging angiography demonstrated splanchnic vein thrombosis (SVT). The final diagnosis was SVT due to MPD (essential thrombocytosis, ET) with JAK2 V617F mutation. After 3 months of treatment with warfarin (≥5 mg/day, to keep target INR values of 1.9-2.5), control MRI angiography and doppler USG demonstrated partial (>%50) resolution of thrombosis with recanalization of hepatopedal venous flow. The patient is still on the same treatment protocol without any complication. CONCLUSION: JAK2 V617F mutation analysis should be a routine procedure in the diagnosis and treatment of kidney transplant patients with thrombosis in uncommon sites.

Impact of histopathology on the outcome of D1/D2 gastrectomies with R0 resection.

AIMS: The primary objective of this study was to clarify the influence of histotype on the outcome of D1/D2 gastrectomized patients with pathologically proven R0 resection. The secondary objective was to demonstrate overall survival (OS), disease-free survival (DFS), and locoregional recurrence rates following standard curative surgery. PATIENTS AND METHODS: All patients had either pure signet-ring cell carcinoma (SRCC)/poorly differentiated adenocarcinoma (PDC) or moderately differentiated adenocarcinoma (MDC) of the stomach, preoperative radiologic evidence of locoregional disease, and no history of neoadjuvant therapy. Standards of surgical treatment were essentially based on the guidelines of the Japanese Research Society for the Study of Gastric Cancer. RESULTS: Between October 2003 and August 2010, seventy-eight patients were enrolled. Twenty-three patients underwent D1 dissection and 55 underwent D2 dissection. The OS and DFS rates were 33.2 ± 5.9 months versus 31.5 ± 4.3 months (p = 0.81) and 28.9 ± 5.6 months vs. 29.3 ± 4.4 months (p = 0.96) in the MDC and SRCC/PDC groups, respectively. Neither the extent of the operation (D1 vs. D2, p = 0.79) nor the histopathologic subtype of the primary tumor (MDC vs. SRCC/PDC, p = 0.91) influenced the OS and DFS. Multivariate logistic regression analysis disclosed pathologic stage (pTNM) as the only significant prognostic determinant of OS (p = 0.007) and DFS (p = 0.0003). CONCLUSION: Properly performed D1 and D2 dissection in our series resulted in a notable (6.4%) locoregional failure rate. In spite of the satisfactory locoregional control achieved by D1 and D2, there was no improvement in the survival figures of stage IIIA-B and IV gastric cancer patients. The histopathologic subtype of the primary tumor disclosed merely a statistical trend on the outcome measures of gastric cancer after curative surgery.

Longitudinal surveillance of mid- and distal rectum cancer in a subset of patients with specific histology.

OBJECTIVE: A prospective study in 82 consecutive patients with mid- and distal rectal adenocarcinomas having specific histology and tumor stage was conducted to asses impact of curative surgery. METHODS: Patients with moderately differentiated adenocarcinoma (MDAC) with or without mucinous differentiation underwent curative resection. Forty patients were in Stage B1-B2 and 42 patients were in Stage C1-C2. Surgery options were: (1) Abdominoperineal resection (APR) for tumors located within 6cm of the anal verge and (2) Tumor specific mesorectal excision (TSME) and low anterior anastomosis (LAA) for those located between 6 to 12cm from the anal verge. The primary endpoints were overall (OS) and disease-free survival (DFS). RESULTS: Patients in Stage B1-B2 had a local failure rate of 15% compared with 31% of patients in stage C1-C2 (p=0.18). Satellite tumor nodule formation (STN) was observed in one patient in B group and in 13/42 (31%) of Stage C tumors. LR did not vary with mucinous differentiation. Only lymph node involvement (N1-3) (p=0.028) had an impact on locoregional recurrence and both lymph node involvement and STN formation influenced disease-free survival (p=0.008). CONCLUSION: Preoperative precise detection of Stage C rectal adenocarcinomas is of utmost importance to facilitate the implementation of therapies for downstaging and for better local and distant control following surgery.

Protective effects of propofol against ischemia/reperfusion injury in rat kidneys.

AIM: The purpose of this study was to investigate and compare the efficiency of propofol in the reduction of injury induced by free radicals in a rat model of renal ischemia/reperfusion (I/R). METHOD: Twenty-four Wistar rats were divided into four groups in our study. Rats in the sham group underwent laparotomy and were made to wait for 120 min without ischemia. Rats in the control group were given nothing with ischemia-reperfusion. Rats in the I/R groups were given propofol (25 mg/kg) and 10% intralipid (250 mg/kg) ip, respectively, 15 min before the ischemia for 60 min followed by reperfusion for 60 min. The kidney tissues of the rats were taken under anesthesia at the end of the reperfusion period. Evaluation of biochemical malondialdehyde (MDA), superoxide dismutase, and catalase activities and histopathological analysis were performed with these samples. RESULTS: I/R significantly increased MDA levels (p < 0.05). Histopathological findings of the control group confirmed that there was renal impairment by tubular cell swelling, interstitial edema, medullary congestion, and tubular dilatation. MDA levels were lower in the propofol group compared to control group (p < 0.05). In the propofol group, the level of histopathological scores is significantly decreased than control and intralipid groups in ischemia-reperfusion. CONCLUSION: Our results demonstrate that I/R injury was significantly reduced in the presence of propofol. The protective effects of propofol may be due to their antioxidant properties. These results may indicate that propofol anesthesia protects against functional, biochemical, and morphological damage better than control in renal I/R injury.

Protective effects of propofol on peritoneal adhesions in cecal ligation and puncture model.

AIM: We assumed that one of the most widely used anesthetic agents, propofol, which is the most widely used anesthetic for sedation, may reduce inflammatory processes and organ injury induced by cecal ligation and puncture. STUDY DESIGN: Bacterial peritonitis was induced in 18 rats by cecal ligation and puncture. The rats were randomly assigned to three groups. Group 1 (n=6) received propofol, group 2 (n=6) received intralipid, group 3 (n=6) was a control group, which did not receive any injection. All animals were killed 14 days later so we could assess the adhesion score. Tissue antioxidant levels were measured in 1-g tissue samples taken from the abdominal wall. RESULTS: The adhesion score was significantly lower in the propofol group than in the control group (p<0.05). The catalase levels were higher in the intralipid and control groups than the propofol groups. CONCLUSIONS: Intraperitoneal propofol reduced the formation of postoperative intra-abdominal adhesions without compromising wound healing in this bacterial peritonitis rat model. Propofol also decreased the oxidative stress during peritonitis (Tab. 1, Fig. 5, Ref. 28). Full Text (Free, PDF) www.bmj.sk.

Anatomical distribution and number of parathyroid glands, and parathyroid function, after total parathyroidectomy and bilateral cervical thymectomy.

The normal distribution of parathyroid glands is well documented. However, this study aims to evaluate the efficacy of total parathyroidectomy (TPTx) and bilateral cervical thymectomy (BCTx) for the treatment of secondary hyperparathyroidism (SHPT) through identifying the location of parathyroid glands with attention to the pattern and frequency of orthotopic and ectopic glands.Between 2013 and 2018, sixty chronic hemodialysis patients with medically refractory SHPT underwent TPTx & BCTx. The adequacy of the operation was defined by the pathological confirmation of at least 4 parathyroid glands, accompanied by an intact parathormone (iPTH) value of <60 pg/mL on postoperative day 1(POD1). Based on their anatomical localizations, four distinct sites were identified for both the upper (Zone I-IV) and lower parathyroid glands (Zone V-VIII).The mean follow-up was 15.2 ±â€Š14.6 months. The mean iPTH values on POD1 were normal in 50 patients, with an average of 11.7 ±â€Š14.4 pg/mL. Ten patients (16.6%) had persistent HPT after the operation, three of whom underwent complementary parathyroidectomy. The surgical success rates after first and second operations were both 83.3%. A total of 235 parathyroid glands were detected. Ninety-two percent of the upper parathyroids were located in Zones I and II. However, almost 28% of the lower parathyroids were ectopic and located in Zones VII and VIII.At least one fourth of the lower parathyroids are ectopic; for this reason, Zones VII and VIII require careful investigation during surgery. For upper parathyroids not found in Zone I-III, total thyroidectomy on the same side is recommended.

Onset of Hypertension in Living Kidney Donors After Donor Nephrectomy: Our 20 Years of Experience.

OBJECTIVES: The development of hypertension can negatively affect cardiovascular and renal outcomes in renal kidney donors. Here, we retrospectively investigated the frequency and risk factors of hypertension development in healthy renal donors at our center. MATERIALS AND METHODS: Living donors of kidney transplants performed between January 1998 and December 2016 were evaluated. Those > 18 years old, having glomerular filtration rate > 70 mL/min/1.72 m², body mass index ≤ 35 kg/m², and proteinuria < 300 mg/day were eligible. Those with a history of diabetes and hypertension and < 1 year of follow-up were excluded. RESULTS: In the 190 included donors, mean follow-up was 56 ± 45 months, mean age was 47 ± 10 years, and 48% were women. Baseline systolic and diastolic blood pressures were 118 ± 13 and 76 ± 8.8 mm Hg. Follow-up showed that 19 donors (10%) developed hypertension. These donors were older and had higher baseline systolic blood pressure (126 ± 13 vs 117 ± 12 mm Hg; P = .003), proteinuria (162 ± 89 vs 117 ± 63 mg/day; P = .05), fasting blood glucose (99 ± 10 vs 94 ± 9.6 mg/dL; P = .03), and uric acid levels (5.4 ± 1.7 vs 4.5 ± 1.2 mg/dL; P = .04). Although these donors had baseline glomerular filtration rates (97 ± 22 vs 104 ± 22 mL/min/1.72 m²; P = .19) similar to other donors, levels were lower at last follow-up (62 ± 14 vs 71 ± 19 mL/min/1.72 m²; P= .03). In multiple regression analysis, preoperative fasting blood glucose, systolic blood pressure, and serum uric acid levels independently predicted hypertension development. CONCLUSIONS: In healthy renal donors, preoperative detailed evaluations can provide important information foreseeing the development of hypertension after nephrectomy.

Evaluation of a Cytomegalovirus Prophylaxis Protocol in Cytomegalovirus-IgG Positive Renal Transplant Recipients (R+).

BACKGROUND: The aim of the study was to evaluate the efficacy of a unique cytomegalovirus- (CMV) prophylaxis protocol in terms of CMV infection and disease progression in CMV IgG positive kidney transplant recipients. METHODS: Achievement of negative CMV load, using concurrent prophylactic intravenous ganciclovir therapy during induction immunosuppression, combined with a 6-month prophylactic course of acyclovir, would yield a reduced incidence of early CMV infection and disease. CMV DNA was tested for at discharge, at the third, and sixth post-op months, and at the occurrence of any event that could be associated with CMV infection. CMV DNA positive patients received ganciclovir treatment until the viral load became negative. CMV replication was monitored using a quantitative PCR method capable of detecting as few as 42.5 copies/mL. All patients were given a maintenance dose of acyclovir. RESULT: The file data of 267 patients who had undergone kidney transplantation between 2007 to 2016 were examined. Thirty-four patients were excluded from the study for various reasons, unrelated to the protocol. Of the remaining 233 patients, 42 (18%) had CMV DNA infection. Three patients had CMV disease (1.3%), 1of whom died of pneumonia. Diabetes mellitus (DM) was a risk factor for CMV DNA positivity (P < .004). CONCLUSION: The incidence of CMV infection and disease is low in renal transplant recipients whose CMV viral load is eliminated after concurrent ganciclovir administration with induction immunosuppression.

Tubular vesicopyelostomy for the management of types 2 and 3 (long-segment) ureteric stenosis after kidney transplantation.

Late ureteral stenosis following kidney transplantation needs immediate correction in order to protect allograft function and requires a complicated surgical procedure. In this study, we present the long-term results of tubular bladder reconfiguration and cystopyelostomy (tubular vesicopyelostomy), an innovative and practical procedure for the management of long-segment ureteric stenosis (types 2 and 3) after transplantation. Between 2002 and 2017, 722 kidney transplant patients were monitored at the University of Medical Sciences, Bozyaka Organ Transplantation and Research Center. Twenty-eight of these patients underwent tubular vesicopyelostomy operation; 17 male and 11 female patients with a mean age of 45.6 ± 10.5 years. Time to surgical intervention for urinary tract obstruction was 122.5 ± 114.7 months. The mean serum creatinine values previous to and 3 days following the tubular vesicopyelostomy operation were 3.46 ± 1.5 mg/dL and 1.75 ± 0.7 mg/dL, respectively (p < 0.0001). Within a mean follow-up period of 55.1 ± 40.9 months, functional grafts were recorded in 22 patients with a mean serum creatinine value of 1.92 ± 0.8 mg/dL. Only one patient developed anastomotic stenosis after the tubular vesicopyelostomy procedure, giving an overall success rate for tubular vesicopyelostomy of 96.4%. Six patients returned to hemodialysis. In five, the underlying etiology was not related to recurrent obstruction or surgical complications. Sixteen patients underwent allograft biopsy after the operation, but features of tubulointerstitial nephritis were seen in only one. Tubular vesicopyelostomy operation is a safe and successful method for the surgical treatment of late and complicated ureteral obstructions with excellent long-term results. It may be a good, practical alternative to other more sophisticated surgical options.

Total thyroidectomy for the treatment of recurrent graves' disease with ophthalmopathy.

OBJECTIVE: To determine the outcome of recurrent Graves' disease with ophthalmopathy (GO) following bilateral total thyroidectomy (TT) in patients with no history of anti-inflammatory treatment with steroids or radioactive iodine treatment. METHODS: From May 2002 to August 2005, 35 patients (27 female, 8 male) with different stages of Graves' disease underwent TT. The degree of ophthalmopathy was assessed by the NOSPECS scoring system and thyrotropin receptor antibody (TRAb) levels were measured for the detection of thyroidal and retro-orbital inflammatory activity before and after surgery. RESULTS: The mean duration of thyroid disease was 21.4 months and mean follow-up was 422 days. Significant improvement, which was defined as complete regression of periorbital oedema accompanied by a > 1 point decrease in NOSPECS, was observed in 30 (85%) patients. The remaining five patients had stable eye disease. The mean TRAb value and NOSPECS score before and after TT were 33.8 U/L versus 3.4 U/L and 3.0 versus 1.52, respectively, and the differences were statistically significant (p < 0.0000). A major reduction in TRAb values achieved after TT was clearly indicative of undetectable inflammatory activity and all the patients demonstrated negative TRAb values within 6 months of the operation. TT was accomplished with very low morbidity (3%) and provided a significant reduction in TRAb levels with attendant improvement in GO in the vast majority of patients in this study. CONCLUSION: TT resulted in a significant reduction in TRAb levels with concomitant regression of recurrent GO in all patients. The operative morbidity was very low and mortality was nil. However, the long-term consequences of permanent hypothyroidism, which is the ultimate result of TT, are of major concern.

Survival outcomes after D1 and D2 lymphadenectomy with R0 resection in stage II-III gastric cancer: Longitudinal follow-up in a single center.

OBJECTIVE: D2 lymphadenectomy (D2-LND) with curative resection (R0) is the cornerstone of gastric cancer treatment. In this study, we compared survival outcomes of D2-LDN with D1-LDN in patients who had undergone curative resection for Stages II and III primary gastric adenocarcinoma. MATERIAL AND METHODS: Between April 1996 and March 2014, 153 consecutive patients with adenocarcinoma of the stomach underwent total gastrectomy with D1-LND or D2-LND. Among those, 118 patients (38 D1 vs. 80 D2) with a complete history and having been followed for at least 1 year after surgery were enrolled. Both groups were compared in terms of demographic and clinico-pathologic characteristics. RESULTS: The mean follow-up was 42.6±52.5 months (mo.). The demographic characteristics of the groups were similar. The Tumor, Node and Metastases (TNM) stage distribution was 25% for Stage II and 75% for Stage III for both groups. Eighteen patients (47.4%) in the D1 and 47 patients (58.8%) in the D2 group were free from locoregional recurrence. The median disease-free survival was 22.0±4.1 mo. for the D1 and 28.0±4.3 mo. for the D2 group (p=0.36). Eight patients (21%) in the D1 and 39 patients (49%) in the D2 group were alive at the last follow-up. The median overall survival (OS) was 22.0±3.7 mo. for the D1 and 31.0±5.4 mo. for the D2 group (p=0.13). The 5-year disease-free survival and OS by the Kaplan-Meier estimates were 41% vs. 51% and 30% vs. 42% in the D1 and D2 groups, respectively. The median 5-year OS for patients with Stages IIIB and IIIC tumors was 14.0±2.2 mo. for the D1 and 20.0±5.0 mo. for the D2 group, respectively (p: 0.048). CONCLUSION: When compared to D1-LND, D2-LND with R0 resection have yielded a trend toward a better outcome in patients with primary gastric adenocarcinoma.

Development of metabolic syndrome after bilateral total thyroidectomy despite the L-t4 replacement therapy: A prospective study.

OBJECTIVES: The literature about the frequency of metabolic syndrome in patients with multinodular goitre and a new onset of metabolic syndrome after total thyroidectomy is limited. The aim of this study was to investigate the effects of total thyroidectomy and thyroid hormones on a new onset of metabolic syndrome in patients who underwent total thyroidectomy and have received thyroid hormone replacement. MATERIAL AND METHODS: Fifty-nine patients who underwent total thyroidectomy for multinodular goitre were included in this prospective study. Patients' height, weight, and waist circumference were measured, and the body mass index was calculated. Peripheral blood samples were obtained preoperatively and at the 12th and 24th month after total thyroidectomy to examine the lipid profile, glucose homeostasis, and thyroid function tests. RESULTS: The lipid profile and blood pressure parameters deteriorated, and the mean body mass index and waist circumference with the metabolic syndrome rates significantly increased at the 12th and 24th months follow-up. Preoperative body mass index (Exp[B] 1.60; p=0.003) was independently associated with metabolic syndrome at the 2nd year after total thyroidectomyin a multivariate regression analysis. CONCLUSION: The frequency and severity of MetS is high in adult patients with non-toxic multinodular goitre after total thyroidectomy. The frequency of metabolic syndrome increased in patients with a high body mass index after total thyroidectomy.

Infections After Renal Transplant in Recipients With Familial Mediterranean Fever: A Life-Threatening Issue.

OBJECTIVES: We evaluated long-term results and infections requiring hospitalization in kidney transplant patients with Familial Mediterranean Fever (associated amyloidosis-type). MATERIALS AND METHODS: We retrospectively reviewed medical records of patients with familial Mediterranean fever with at least 1-year posttransplant follow-up. Kidney transplant recipients with primary glomerulonephritis and equivalent demography, immunity status, and follow-up comprised the control group. RESULTS: In 32 patients with familial Mediterranean fever versus 25 control patients (mean follow-up 82 ± 57 vs 79 ± 54 mo; P = .82), average serum creatinine values were 1.7 ± 0.9 versus 1.5 ± 1.0 mg/dL (P = .41) at discharge, 1.4 ± 0.4 versus 1.3 ± 0.5 mg/dL (P = .44) at 1 year, 1.4 ± 0.6 versus 1.3 ± 0.5 mg/dL (P = .63) at 3 years, and 2.0 ± 1.5 versus 2.1 ± 1.5 mg/dL (P = .92) at last follow-up. Groups were not statistically different regarding average inpatient and number of hospitalizations due to infections at 1 year; however, at last follow-up, 26 patients with familial Mediterranean fever (81%) had 8.6 average admissions and 13 control patients (52%) had 2.8 average admissions (P = .02, P < .01). Early posttransplant, both groups were taking a triple drug immunosuppression regimen. However, at 1 and 3 years posttransplant, withdrawal and/or minimization occurred in 40.6% and 83.3% of patients with familial Mediterranean fever and 28% and 55.5% of control patients (P < .05, P < .05). During follow-up, 6 familial Mediterranean fever patients (18.7%) and 2 control patients (8%) died (P = .23). CONCLUSIONS: Although renal transplant patients with associated amyloidosis-type familial Mediterranean fever and those with glomerulonephritis have similar rejection and/or graft loss rates, hospital admissions due to infection and increased mortality are more common in the familial Mediterranean fever group, with immunosuppression drug withdrawal.

Late Diagnosis of E148Q Mutation-Positive Familial Mediterranean Fever in a Kidney Transplant Patient With Fever of Unknown Origin: A Case Report.

Fever of unknown origin is a rare condition after solid organ transplant and is generally associated with atypical infections (eg, tuberculosis, fungal infections) and/or lymphoproliferative disorders. Here, we present a kidney transplant patient with a late diagnosis of E148Q mutation-positive familial Mediterranean fever as the cause of fever of unknown origin. A 22-year-old female patient with a previous history of 4 years of hemodialysis and unknown primary renal disease received a deceased-donor kidney transplant at our center 5 years previously. She had an uneventful course in the first 3 years following transplant. After this period, she was hospitalized 3 times during a 4-month period with fever, nausea, vomiting, and atypical abdominal pain. At that time, hemogram results were unremarkable, except for mild leukocytosis and slightly elevated acute-phase reactants; blood, urine, and throat cultures were negative, and there were no remarkable findings on imaging tests. Fever was controlled within 48 hours by administering empiric ampicillin-sulbactam therapy and discontinuing immunosuppressive treatment except steroids. Three successive hospital admissions owing to similar complaints suggested periodic fever syndrome, and therapy with 1 g/day colchicine led to an excellent clinical response with no recurrence of fever or other symptoms. An FMF gene mutation analysis revealed heterozygous E148Q mutation positivity. Continuing the current treatment regimen, the patient did well during at approximately 1.5 years of follow-up. In the Mediterranean region population, familial Mediterranean fever should be considered in the diagnosis of fever of unknown origin in patients who have undergone renal transplant. E148Q mutation-positive familial Mediterranean fever has a subclinical course and renal manifestations that differ from AA amyloidosis during childhood and may be responsible for de novo familial Mediterranean fever after renal transplantation.

Phyllodes Tumor of Anogenital Mammary-like Glands with Diffuse Pseudoangiomatous Stromal Hyperplasia.

Anogenital mammary-like glands may give rise to various pathologic lesions identical to those known in mammary pathology. Tumor occurring in the anogenital region is extremely rare. The histogenetic origin of this tumor is controversial as it is being debated whether such lesions evolve from ectopic breast tissue and most recently, anogenital mammary-like gland. We report a 28-year-old girl who presented with a painless mass in the anogenital region, which was subsequently excised. Microscopic examination revealed morphologic pattern characteristic of benign phyllodes tumor with pseudoangiomatous stromal hyperplasia. We present this case to emphasize the importance of recognizing this uncommon lesion occurring at an extremely unusual site. We also discuss the histogenesis of phyllodes tumor and related lesions occurring in the anogenital region in light of the current literature along with a brief review of the previously reported cases of anogenital mammary-like glands.

The efficacy and immunogenicity of Pneumo-23 and ACT-HIB in patients undergoing splenectomy.

BACKGROUND: The objective of this prospective study is to validate the efficiency of Streptococcus pneumoniae and Haemophilus influenzae vaccines in splenectomized patients via the demonstration of seroconversion and uninterrupted ability for opsonization. METHODS: Thirty-two adult patients (18 males, 14 females; mean age 46.1 years; range 18 to 79 years) who underwent elective or urgent splenectomy for various benign and malignant hematological disorders, splenic trauma and splenic masses were reviewed. Pneumo-23 and Act-HIB were administered to all patients on routine basis. In order to demonstrate the ongoing opsonizing capacity of the immune system and the seroconversion of immunoglobulins after vaccination, antibody titers of IgG and IgM and plasma C3 and C4 levels were quantitatively measured. RESULTS: The operative morbidity was 9% and overall mortality was 16%, with no early postoperative death in this series. Five patients with various malignant disorders died due to dissemination of their primary tumor. None of the patients with benign hematological disorders or those with splenic trauma died during the mean follow-up of 427 days. Furthermore, death from overwhelming postsplenectomy infection was nil in our clinical survey. All of the patients including those with malignancy had normal IgG (mean: 1383.1 mg/dL) and IgM levels (mean: 80.9 mg/dL) during discharge and at the last follow-up. Among the patients with benign hematological disorders, splenic trauma and splenic masses necessitating splenectomy, C3 and C4 levels were entirely within normal limits with a mean of 108.8 mg/dL and 21.4 mg/dL, respectively. CONCLUSION: This preliminary study reveals adequate seroconversion of immunoglobulins in all patients and normal C3 and C4 levels in patients with benign hematological disorders and splenic trauma. Moreover, none of the patients in the latter group had S. pneumoniae or H. influenzae infection nor did they expire due to overwhelming sepsis during the follow-up period. Long-term follow-up is required to determine the continuation of this immunologic response and the necessity of repeated vaccination.