Relationship of preoperative venous and arterial imaging findings to outcomes of brachio-basilic transposition fistulae for hemodialysis: a prospective clinical study.

PURPOSE: To evaluate the maturation and patency of transposed brachio-basilic fistulae that had been chosen based on the results of preoperative imaging techniques. METHODS: Among 215 patients admitted to our clinic requiring arteriovenous fistulae between May 2004 and September 2005, 59 were scheduled for a transposed brachio-basilic fistula procedure. The relationship between demographic data, laboratory values, invasive and noninvasive imaging studies with patency and maturation time of the fistulae were evaluated by univariate analyses. RESULTS: Primary and secondary patency rates were 82% and 97% at 6 months 72% and 92% at one year respectively. The only parameter found to affect maturation time was basilic vein diameter. The maturation time was 59.3+/-22.3 days (range 32-92 days) for veins less than 3mm in diameter and 24.7+/-4.4 days (range, 21 to 34 days) for those with larger diameters. The number of previously failed fistulae correlated with a decrease in primary patency time. The primary patency rate at 1 year was 58.9% for patients whose preoperative arterial flow rate was below 70cm/sec, while it was 93.3% when the flow was greater. CONCLUSION: We believe that this type of fistula should be the first option in patients in whom the cephalic vein is inappropriate for a vascular access. Preoperative evaluation of the arterial system as well as a history of previous access failure may be considered predictive parameters for the patency of the fistulae.

Postsurgical complications in living-related liver donors.

From September 2001 until March 2007, we performed 127 living-donor liver transplantations in our transplantation center. Of 127 donors, 74 were men and 53 women, of overall mean donor age of 35.2 +/- 9.3 years (range, 20-56 years). Ninety-six (75.6%) were first-degree relatives, 18 (14.1%) were second-degree relatives, and 13 (10.3%) were spouses. We performed 34 (26.7%) left hepatic lobectomies, 33 (25.3%) left lateral segmentectomies, and 60 (48%) right hepatic lobectomies. The mean percentages of remnant to donor total liver volume for the right, left, and left-lateral lobectomies were 41.7%, 67.8%, and 75.1%, respectively. The mean length of patient postoperative hospital stay was 7.4 +/- 3.1 days (range, 3-33 days). There was no postoperative mortality. Ten complications occurred in 7 of the 127 donors (5.5%). Most complications were treated with radiologic interventions. In conclusion, donor safety should be the primary focus in living-donor liver transplantation. More experience, improved surgical techniques, and meticulous donor evaluation will help to minimize morbidity and mortality for living liver donors.

Corner-saving renal artery anastomosis for renal transplantation.

Renal transplantation is the preferred treatment for most patients with end-stage renal disease. Postoperative vascular complications that significantly affect graft loss include stenosis and renal artery thrombosis. Our transplant team has performed 1635 procedures since 1975. Since December 2003, we have performed a corner-saving technique for the renal artery anastomoses in 183 recipients. In this study, we retrospectively analyzed the outcome data from these procedures in 43 women and 140 men of overall mean age of 31.6 years (range, 7-66 years). Graft tissue was obtained from deceased donors in 47 and from living donors in 136 recipients. The mean age of the donors was 39.8 years (range, 6-67 years). The graft renal arteries were spatulated from the posterior walls of the renal artery to provide wide anastomoses. Using this technique, a renal artery stenosis occurred at 5 months after renal transplantation in 1 recipient (0.54%). It was treated successfully with balloon angioplasty and placement of an intraluminal stent. We did not encounter any instances of renal artery thrombosis during a mean follow-up of 20.6 +/- 11.6 months (range, 1-40 months). During follow-up, 5 recipients died, and 9 returned to hemodialysis. At the time of this writing, the remaining 169 recipients (92.3%) are alive with good graft function. In conclusion, owing to its low complication rate, we believe our new corner-saving technique to be the safest way to perform a renal artery anastomosis.

Results of kidney transplantation between spouses: a single-center experience.

The shortage of cadaveric kidneys is growing in Turkey despite intensive efforts to find a solution. Living related donors are the primary source of kidneys in developing countries. When a first-degree relative of the patient is not available, a second-degree relative or a genetically unrelated but emotionally related donor, such as a spouse, becomes an alternative. From November 1985 to June 2006, 81 living unrelated kidney transplantations were performed between spouses at our hospital. Seventy-one of the donors were women, and 10 were men. The mean donor age was 33.9 +/- 8.5 years and the mean patient age was 38.5 +/- 8.8 years. The posttransplantation patient and graft survival rates were. 1 year: 93% patient survival, 83% graft survival; 3 years: 90% patient survival, 78% graft survival; and 5 years: 83% patient survival, 76% graft survival. During the posttransplantation period (mean, 82.5 +/- 61.4 months range, 6-216 months), seven patients died: three from sepsis, one from gastrointestinal hemorrhage, two from myocardial infarction, and one from pancreatitis. Three of those seven patients died with a functioning graft, and the seven other grafts were lost because of chronic rejection. To obstruct the underground trade in organs sold for transplantation, our center does not accept living unrelated organ donor candidates other than a spouse. Interspousal kidney transplantation is an important option with good clinical results. It provides the couple with a better quality of life, offers the opportunity to share the joy of giving, and enables a husband and wife to receive the "gift of life" from each other.

Expanded criteria for hepatocellular carcinoma and liver transplantation.

In this study, we evaluated our early results of liver transplantation for hepatocellular carcinoma (HCC). Between January 2004 and June 2006, 26 patients (4 females, 22 males; aged 1.1-65 years) with preoperatively diagnosed or incidental HCC underwent liver transplantation at our center. Inclusion criteria (independent of tumor size and number of tumor nodules) were no invasion of major vascular structures and no evidence of extrahepatic disease. In 13 of the patients, tumors were beyond the Milan criteria. At this writing, at a mean follow-up of 16.5 months (range, 1-31 months), all patients were doing well with excellent graft function. The longest survival is 2.5 years, and our patient survival rate is 100%. There has been only 1 tumor recurrence, which occurred 4 months after liver transplantation. In conclusion, liver transplantation provides long patient and disease-free survival, even in patients with HCC that exceeds the Milan criteria.

Comparison of histidine-tryptophan-ketoglutarate and University of Wisconsin in living-donor liver transplantation.

For cadaveric transplantations, histidine-tryptophan-ketoglutarate (HTK) and University of Wisconsin (UW) solutions have been shown to engender similar outcomes. In September 2004, our institution changed from UW to HTK as the primary preservation solution for liver and kidney transplantations. We reviewed records of living-donor liver transplant recipients from September 2001 to December 2005. This study compared early postoperative outcomes of liver transplantation using the 2 solutions. Perfusion was performed first via the portal vein and then via the hepatic artery until the outflow became clear. Patients were compared based on the organ preservation solution. The analysis included patient demographics, early postoperative complication rates, mortality rates, number of acute rejection episodes, costs for preservation solutions, and results of 1-, 7-, 14-, and 30- day liver function tests. Patients in both groups were managed with similar operative techniques, immunosuppressive regimens, and donor liver criteria. Statistical analyses were performed with chi- square and Mann-Whitney U tests. Donor and patient demographics were similar. No statistically significant differences were observed between the groups with regard to posttransplantation liver biochemistry, complication rates, number of acute rejection episodes, and mortality rates. The mean infused volume of preservation solution was 1000 +/- 400 mL (range, 500-2000 mL) for all patients. These volumes corresponded to a cost savings of US 148 dollars/L when using HTK solution. In conclusion, UW and HTK were equally effective and safe for perfusion of living-donor liver grafts; however, the use of HTK solution provided significant cost savings.

Recurrent glomerular diseases after renal transplantation.

INTRODUCTION: Recurrent glomerular diseases are important causes of graft dysfunction after renal transplantation. As the outcomes of transplantation continue to improve, the problem of recurrent diseases in the transplanted kidney have become evident. The purpose of our study was to determine the risk factors for and the incidence of recurrence in the posttransplant period as well as their impact on graft survival rates. METHOD: We retrospectively analyzed 49 patients with glomerular diseases due to membranoproliferative glomerulonephritis (n = 26); focal segmental glomerulosclerosis (FSGS, n = 18); and systemic lupus erythematosus (n = 5). The mean follow-up was 9.5 years. RESULTS: Recurrent disease was detected in 30 of 49 patients after a mean posttransplant follow-up of 28.1 months (range = 1 to 157) and their average graft survival was 41.3 months. Nineteen patients were recurrence-free with a mean graft survival of 79.4 (range = 15 to 158) months (P < .05). One patient with FSGS, showed disease-recurrence in her third transplant after having experienced recurrences in the former grafts. In all six patients with HLA haplotype B8, recurrence was observed at a mean of 19.5 +/- 9.8 months. The only risk factor that was identified was this HLA haplotype. CONCLUSION: Recurrent disease a significant problem after renal transplantation is associated with decreased graft survival. The donor HLA type may be associated with risk, which should be clearly discussed with both the living donor and the recipient candidate.

Human leukocyte antigen-G, a new parameter in the follow-up of liver transplantation.

Human leukocyte antigen-G (HLA-G) displays immunotolerogenic properties toward effector cells in graft rejection through inhibition of natural killer (NK) and cytotoxic T lymphocyte (CTL)-mediated cytolysis and CD4+ T-cell alloproliferation. CD4(+)CD25(+)high regulatory T (Treg) cells are pivotal for the maintenance of self-tolerance of pathogenic alloresponses after solid organ or bone marrow transplantation in murine model systems. The aim of this study was to investigate whether there was an association between soluble and membrane-bound HLA-G levels on Treg cells and liver graft prognosis. For this purpose, we studied 37 liver transplant patients and 13 healthy blood donors. To investigate the expression of HLA-G on the surface of peripheral mononuclear (PMNL) cells, we have used monoclonal antibodies in flow cytometry to estimate CD4, CD25, CD45, and HLA-G content. HLA-G serum levels were determined by ELISA. We observed a correlation between sHLA-G serum levels and liver function tests. After a month of HLA-G decrease in serum levels, liver function tests such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), direct bilirubin (DB), total bilirubin (TB), and alkaline phosphatase (ALP) were above normal levels, suggesting liver dysfunction or rejection. Considering these results, we concluded that the increased sHLA-G in serum and on cell surfaces may afford preliminary data on the prognosis and response to treatment in liver transplant patients.

Role of donor age and acute rejection episodes on long-term graft survival in cadaveric kidney transplantations.

Cadaveric donors can provide an effective solution to the problem of organ shortage, and many factors that may affect the functioning and survival of cadaveric kidneys have been studied. We aimed to clarify the impact of donor age and acute rejection episodes on long-term graft and patient survival in patients receiving cadaveric renal transplants. We retrospectively evaluated the long-term outcomes of 207 patients who had received cadaveric renal transplants between 1985 and 2004. Mean recipient age, HLA mismatch, mean donor age, delayed graft function (DGF), mean cold ischemia time, acute rejection episodes in the first 6 months after transplantation, and 1-, 3-, and 5-year graft survivals were evaluated. Two study groups were created according to donor age: group 1 (n = 126) was composed of patients receiving kidneys from donors younger than 50 years, and group 2 (n = 81) was composed of patients receiving kidneys from donors 50 years of age or older. Mean recipient age, HLA mismatch, and mean cold ischemia time between groups were not different. The DGF rate in group 1 was 40% (n = 50) and in group 2 was 46% (n = 37) (P > .05). The 1-, 3-, and 5-year survival rates of patients without acute rejection within the first 6 months after transplantation in group 1 (58/126; 46%) versus those in group 2 (46/81; 57%) were 95% versus 90%, 65% versus 60%, and 40% versus 35%, respectively (P > .05). The 1-, 3-, and 5-year graft survival rates of patients with acute rejection within the first 6 months in group 1 (n = 68) versus those in group 2 (n = 35) were 93% versus 89%, 71% versus 55%, and 44% versus 28%, respectively (P = .005). There was no significant difference in 1-, 3-, and 5-year survival rates between patients with DGF in both groups. Acute rejection episodes within the first 6 months after cadaveric transplantation, especially in patients receiving kidneys from donors older than 50 years, were shown to affect 5-year survival of the kidney graft. However, cadaver age alone had no negative effect on 5-year graft survival rates. Cadaveric donors older than 50 years may be a solution to the organ shortage in the treatment of end-stage renal disease.

OKT3 treatment for steroid-resistant acute rejection in kidney transplantation.

Orthoclone (OKT3, Ortho Biotech Inc, USA) monoclonal antilymphocyte antibody is a powerful T-cell-specific immunosuppressive agent. OKT3 has been used for induction therapy in kidney and liver transplantation, as well as to treat acute or steroid-resistant acute rejection episodes (ARE). This study was a retrospective analysis of 43 renal transplant recipients who developed steroid-resistant ARE and were treated with OKT3 between September 1994 and June 2004. The recipients were 36 men and 7 women of mean age 32.7 +/- 11.6 years (range, 19 to 48 years). The mean time from transplantation to OKT3 treatment was 7.2 +/- 6.7 months. Thirty-four episodes (79.1%) responded to OKT3 therapy with improved graft function, but the remaining 9 (20.9%) grafts did not respond. Among the 34 OKT3 responders, the mean serum creatinine decreased from 3.96 +/- 2.5 mg/dL to 2.45 +/- 1.77 mg/dL after treatment. Eleven (25.6%) of the 43 patients experienced minor side effects: fever, dyspnea, tachycardia, bradycardia. One patient (2.3%) developed acute pulmonary edema; one (2.3%), cytomegalovirus infection; and eight (18.6%), bacterial infections. The 1-, 3-, and 5-year graft survival rates for the 34 patients who responded to OKT3 therapy were 96%, 93%, and 85%, respectively. All patients are currently alive. The results indicate that OKT3 is a safe, effective treatment choice for steroid-resistant ARE in kidney transplantation.

Vascular complications after liver transplantation in pediatric patients.

Vascular complications are the major cause of morbidity and mortality after liver transplantation, particularly in pediatric patients, owing to their smaller vascular diameters. Between September 2001 and June 2004, among 21 (16 boys and 5 girls) pediatric liver transplantations of mean age 8.3 +/- 5.1 years, hepatic arterial thrombosis (HAT) was diagnosed in 2 (9.5%) patients, and hepatic arterial stenosis (HAS) in 4 (19.4%). Vascular patency was evaluated with Doppler ultrasonography every 12 hours in the first postoperative week and daily in the second postoperative week. When occlusion was suspected, conventional angiography was performed. Thrombectomy was performed in one patient, and thrombectomy and reanastomosis were performed in another patient with HAT. Two patients with HAS were treated with balloon angioplasty. A third patient was treated with balloon angioplasty and endoluminal stent placement at the same time. The last patient with HAS had an intimate dissection, which occurred 24 hours after balloon angioplasty, that was treated with subsequent endoluminal stent placement. Mean follow-up for the patients with vascular complications was 9.5 +/- 5.7 months (range, 4 to 18 months). The overall mortality rate was 14.1% (3/21); however, no deaths were caused by vascular complication. Routine Doppler ultrasonographic evaluation is an effective choice for diagnosing vascular complications seen after liver transplantation. Immediate surgical intervention is required for acute vascular complications, whereas late complications may be treated with balloon angioplasty and/or endoluminal stent placement.

Comparison of long-term quality of life after laparoscopic and open cholecystectomy.

BACKGROUND: Although many studies have compared open and laparoscopic procedures, showing many advantages in favor of the laparoscopic technique during the early postoperative period, only a limited number of reports in the literature compare the two techniques during the later follow-up period with regard to quality of life. This study aimed to compare the effects of these two cholecystectomy techniques on the quality of life and clinical outcome of the patients during long-term follow-up evaluation. METHODS: This study evaluated 200 patients who underwent cholecystectomy operations with either technique between 1993 and 1999 in our department. There were 100 patients in each group. Both groups were similar with respect to age, gender, body mass indexes, American Society of Anesthesiology (ASA) scores, and indications for surgery. The Medical Outcome Study Short Form 36 Health survey (SF-36), which includes 36 items, was used for evaluating the quality-of-life index. In addition to this, a system-specific instrument for gastrointestinal diseases was used to investigate clinical outcome. RESULTS: The mean administration time for the questionnaire was 46.8 +/- 18.7 months in the laparoscopic cholecystectomy (LC) group and 41.5 +/- 16 months in the open cholecystectomy (OC) group. Statistically significant differences were noted in the scores for all eight SF = 36 health status domains in favor of laparospopic surgery. No statistically significant difference was found for abdominal pain, location of the pain, referral to a doctor for the pain, accompanying symptoms, relieving factors for the pain, distention, and dyspeptic complaints, usage of antacid therapy, weight changes, changes in bowel habit, need for a special diet, or sexual functions between the two groups. CONCLUSIONS: The gastrointestinal clinical symptoms were similar in the two groups during the long-term follow-up evaluation, but laparoscopic cholecystectomy was found to be significantly superior to the open technique with respect to the quality of life over the long term.

Exotic arteriovenous fistulas for hemodialysis.

The rate of patients with exhausted upper extremity arteriovenous fistula (AVF) sites who have lost all chances for a conventional upper extremity AVF has been increasing in line with the general increase in the hemodialysis patient population. In this prospective study, we report the early and late follow-up results of "exotic" AVFs in which central veins are used for the outflow. Patients having no chance for an upper extremity AVF based on previous catheterization, surgical AVF history, detailed physical examination, and radiological assessment, were included in the study. Between June 1999 and January 2003, 27 central AVFs were created with a 6 mm synthetic vascular graft in 26 patients. The inflow artery was the proximal axillary artery in all except one. All but one operation was done by the same surgeon. The outflow vein was the internal jugular vein in 16 and infraclavicular axillary vein in 11 cases. One-year primary and secondary graft patency rates were 33.33 +/- 10.49 and 57.06 +/- 11.29, respectively. The early complications were facial edema and hemiparesis, both of which resolved spontaneously. The only late complication, pseudoaneursym, was treated by a graft interposition. In selected patients who have no suitable upper extremity vessels for an AVF, the central veins may be used with an acceptable success rate. Another advantage of this procedure is the avoidance of undesired femoral interventions; sometimes it may be the only opportunity and lifesaving for the patient.

Diagnosis and treatment of xanthogranulomatous cholecystitis.

BACKGROUND: The aim of this study was to review our case load of the treatment and outcomes of patients with xanthogranulomatous cholecystitis (XGC). PATIENTS AND METHODS: Data about 21 patients were reviewed retrospectively to determine age, clinical symptoms and findings, preoperative screening, operative findings, surgical history, length of hospital stay, and postoperative complications. RESULTS: There were 14 men and 7 women (mean age, 65 ± 11.3 yr). Preoperative ultrasonography of 17 patients showed a gallbladder stone in 14 patients, adenomyomatosis plus stones in 2 patients, and a polyp in 1 patient. There were 5 patients with acute cholecystitis and 16 patients with chronic cholecystitis. Gallbladder wall thickening was noted in 3 of the 12 patients who had abdominal computed tomography. Frozen section examinations were done in 5 patients. Radical cholecystectomy was done in 1 patient because of suspected carcinoma. CONCLUSIONS: It is difficult to diagnose XGC preoperatively or intraoperatively, and the definitive diagnosis depends exclusively on pathologic examination.

Biliary complications after pediatric liver transplantation.

OBJECTIVES: After liver transplantation, biliary complications are more prevalent in pediatric patients, with reported rates varying between 15% and 30%. METHODS: We retrospectively analyzed biliary complications observed in 84 pediatric liver transplantation patients between July 2006 and September 2012. Biliary reconstruction was accomplished via a duct-to-duct anastomosis in 5 (83.3%) of the 6 patients receiving whole liver grafts and in 44 (56.4%) of the 78 patients who received a segmental live donor graft. For the remaining 34 patients with living donor and 1 patient with whole liver graft, Roux-en-Y hepaticojejunostomy was the preferred method. RESULTS: Post-transplantation biliary complications were encountered in 26 patients (30.1%). The biliary complication rate was 38% in 49 duct-to-duct anastomosis, whereas it was 20% in the hepaticojejunostomy group consisting of 35 recipients. Thirteen of the 18 biliary leaks were from duct-to-duct anastomoses and the remaining 5 were from the hepaticojejunostomies and 6 of the 8 biliary strictures were observed in recipients with duct-to-duct anastomosis. In 19 of the 26 patients, the biliary complications were successfully treated with interventional radiologic procedures and 1 was treated with stent placement during endoscopic retrograde cholangiopancreatography. CONCLUSIONS: Percutaneous interventional procedures are valuable, effective, and life-saving therapeutic alternatives for the treatment of bile leaks and strictures after pediatric liver transplantations.

Neurocognitive functions in pediatric renal transplant patients.

Neurocognitive dysfunction is one of the major complications of chronic renal failure (CRF). Uremic state during CRF encompasses a wide spectrum of neurobehavioral and neurological disturbances. Recent studies showed that the pathophysiology of neurocognitive dysfunction in CRF is related to plasma levels of uremic solutes. Successful renal transplantation improves renal, metabolic, and endocrine functions and the quality of life. The aim of our study was to determine the state of neurocognitive function in pediatric renal transplant recipients. We prospectively performed a neurological examination and neuropsychological test battery (Bender-Gestalt Test, Cancellation Test, and Visual and Auditory Number Assay Test) in 20 pediatric renal transplant recipients between 6 and 16 years of age. Twenty healthy children and 20 children with CRF were included in the study as the control groups. Mean age of the renal transplant recipients was 13.50 ± 3.40 years old. Mean evaluation time after transplantation was 2.0 ± 0.5 years. Bender-Gestalt Test result was abnormal in 40% of patients. The results of the Cancellation Test and the Visual and Auditory Number Assay Test showed significant decline in pediatric renal transplant patients when compared with the control. We found that neurocognitive dysfunction was frequent in pediatric renal transplantation patients. Awareness of this potential problem may be helpful for early recognition and treatment. Our findings suggest that periodic neurocognitive assessments may be indicated in transplant recipients.

Factors associated with hyperbilirubinemia after living donor hepatectomy.

PURPOSE: Increased serum bilirubin levels are common after living-donor hepatectomy. Little information is available on the characteristics and clinical significance of serum bilirubin levels soon after donor hepatectomy. MATERIALS AND METHODS: Since September 2001, we performed 229 living donor hepatectomies for living-donor liver transplantations. The 128 men and 101 women had a mean age of 34.4±8.9 years (range, 19-66). Most donors were parents (n=110; 48%). We transplanted 110 right lobes, 46 left lobes, and 73 left lateral segments. Donors were divided into 2 groups: Group 1 consisted of 181 donors who showed total bilirubin levels of <3 mg/dL, and group 2, 48 donors with levels of ≥3 mg/dL on postoperative day 3. Preoperative total bilirubin level, ratio of preoperatively estimated remnant liver volume, surgical duration, gender, age, graft type, blood transfusions, and preoperative liver biopsy findings were evaluated as risk factors for hyperbilirubinemia. RESULTS: The mean postoperative maximum total bilirubin level was 2.26±1.49 mg/dL (range, 0.36-9.9). Remnant liver volume<40%, preoperative bilirubin levels>1 mg/dL, right lobe donor hepatectomy, male donor, and abnormal liver biopsy findings were significant risk factors for postoperative hyperbilirubinemia (P=.015, P=.02, P<.01, P=.008, and P=.023 respectively). Also donor age>50 years showed a slight effect on hyperbilirubinemia (P=.052). Blood transfusions and surgical times were not significant factors. CONCLUSION: Donor safety is paramount, requiring thorough donor evaluation. Extensive liver resection may result in transient functional impairment. Several factors are believed to play roles in the development of postoperative hyperbilirubinemia after living-donor hepatectomy.

Effect of secondary interventions on patency of vascular access sites for hemodialysis.

PURPOSE: To determine the impact of secondary procedures performed to maintain arteriovenous fistula (AVF) and arteriovenous graft (AVG) patency. METHODS: There hundred and eighty six vascular access procedures were retrospectively evaluated. 156 (40.4%) patients required radiological interventions to treat acute thrombosis, swelling of the extremity with the access site, insufficient hemodialysis, or stenosis at an anastomotic site. RESULTS: The 386 cases comprised 106 AVGs and 280 AVFs. In 138 of the 156 cases, which required a radiological intervention, the treatment was successful and saved the vascular access site. The unassisted post-intervention patency time for these 138 successful cases was 13.1 +/- 12 months (range, 1-65 months). Twenty-nine (63%) of the 46 access sites treated with surgical thrombectomy were saved. CONCLUSIONS: Frequent, regular follow-up of hemodialysis patients with vascular access sites is the best way to diagnose problems early and allow the best chance of long-term function.