Choroidal Vascularity Index and Choroidal Thickness Changes Following Renal Transplantation.

Objectives: This study aimed to evaluate changes in subfoveal choroidal thickness (SFCT), choroidal vascularity index (CVI), estimated glomerular filtration rate (GFR), mean arterial pressure (MAP), and intraocular pressure (IOP) after renal transplantation. Materials and Methods: A total of 49 renal transplantation patients were included in this prospective study. CVI and SFCT on enhanced-depth imaging optic coherence tomography (EDI-OCT), MAP at the cubital fossa, GFR, and IOP were measured preoperatively and at postoperative 1 week and 1 month. In the analysis of EDI-OCT images, luminal area (LA) and stromal area of the choroid were determined using the image binarization method. CVI was defined as the ratio of LA to total choroid area. The effects of GFR, IOP, and MAP on CVI and SFCT were investigated. Results: The study included 23 women (47%) and 26 men (53%) with a mean age of 26.28±8.25 years (range: 18-52). Changes between preoperative, postoperative 1-week, and postoperative 1-month GFR values, CVI, and SFCT measurements were evaluated. There were significant differences between preoperative and postoperative GFR and SFCT measurements (p<0.001), but no significant differences between preoperative and postoperative CVI (p=0.09), MAP (p=0.14), or IOP (p=0.84) measurements. Conclusion: The present study demonstrated that SFCT increased significantly with GFR, while there was no change in CVI values.

An Alternative Abdominal Closure Technique After Pediatric Liver Transplant: Bogota Bag Technique.

OBJECTIVES: In conditions such as large-for-size syndrome, postreperfusion hepatic edema, and intestinal edema, primary closure of the abdominal wall can cause respiratory complications and thrombosis of vascular structures. Here, we compared results of primary abdominal closure versus a temporary patch closure technique (the Bogota bag technique) in pediatric liver transplant recipients. MATERIALS AND METHODS: We performed primary abdominal closure in 295 recipients. In 39 pediatric liver transplant recipients, the Bogota bag technique was used as the abdominal closure technique because of suspected intraoperative tense abdominal closure. In patients who had the Bogota bag technique, we sutured the sterilized saline bag to the skin at the edge of the defect by shaping the defect so as not to cause abdominal hypertension. Primary abdominal closure was achieved in patients after control laparotomies at 48-hour intervals. RESULTS: The mean age of the primary abdominal closure group was 8.38 years, whereas the mean age of the Bogota bag group was 2 years. The average weight of patients in the primary abdominal closure group was 26.38 kg, and the average weight of patients in the Bogota bag group was 7.93 kg. Biliary atresia was the most common indication in both groups. Mean length of hospital stay was 21 days in the primary abdominal closure group and 24 days in Bogota bag group. Six patients in the Bogota bag group died from sepsis or bleeding in the early postoperative period. In the Bogota bag group, wound closure was achieved within 2 weeks in 25 patients and within 3 weeks in 8 patients. CONCLUSIONS: Temporary patch closure techniques can be used safely in low-weight and young children, children with large-for-size grafts, and those who display increased intra-abdominal pressure.

Vascular Complications in Pediatric Liver Transplants and Their Management.

OBJECTIVES: The blood supply of the liver occurs through the hepatic artery and portal vein. Outflow of blood circulation in the liver is via the hepatic veins. Any disruption in this blood circulation results in deterioration of liver functions. In this study, we evaluated early vascular complications in pediatric liver transplant recipients seen at our center. MATERIALS AND METHODS: From November 1988 to December 2021, our team has performed 701 liver transplant procedures, which have included 334 pediatric liver transplants. Among these pediatric liver transplant recipients (mean age of 7.34 y), 176 were male patients. Nineteen patients (5.7%) were recipients of deceased donors. Reason for liver failure was mainly biliary atresia (n = 169). Mean weight of recipients was 23.3 kg. Most graft types were left lateral grafts (n = 204). RESULTS: Three patients had hepatic vein complications. All 3 patients were successfully treated with interventional radiological methods by placing a stent in the anastomosis region. Portal vein complications occurred in 3 patients. One patient had hemostasis performed surgically. The second patient had surgically revision of the anastomosis because of thrombus formation. Because of stenosis of more than 50% in the portal vein anastomosis, the third patient required stent placement in the anastomosis region. Hepatic artery complications occurred in 54 patients: 31 patients had hepatic artery thrombosis, 13 patients had hepatic artery stenosis, 7 patients had bleeding from hepatic artery anastomosis, 2 patients had hepatic artery dissection, and 1 patient had pseudoaneurysm in the hepatic artery. Forty-three of these patients were successfully treated with interventional radiological methods and 11 required surgical treatment. CONCLUSIONS: Vascular complications after liver transplant can cause deterioration in hepatic functions and acute liver failure. Vascular complications can be successfully treated in experienced organ transplant centers.

Our Pediatric Liver and Kidney Transplant Activities in 2021.

OBJECTIVES: In children with end-stage renal disease, chronic liver failure, or acute liver failure, liver transplant and kidney transplant are the most effective modalities for better clinical outcomes compared with other therapies. However, children are particularly susceptible to surgical complications, so pediatric solid-organ transplants should be reserved for centers with substantial experience and multidisciplinary expertise. Here, we assessed liver and kidney transplants performed at our center in 2021. MATERIALS AND METHODS: From November 3, 1975, to December 31, 2021, we performed 701 liver transplants and 3290 kidney transplants. From January 1, 2021, to December 31, 2021, we performed 21 liver transplants (19 in children) and 114 kidney transplants (12 in children). We recorded age, sex, body mass index, comorbidities, etiologies, laboratory values, and clinical outcomes. RESULTS: For the year 2021, we performed 19 pediatric liver transplants and 12 pediatric kidney transplants. Mean age of liver recipients was 3.4 years, and 8 were male patients. The most common etiology was biliary atresia (n = 7). All liver grafts were from living related donors who were first-degree (n = 16) or second- degree (n = 3) relatives of the recipients. Mean hospital stay was 17.6 days. All but 2 liver transplant recipients were discharged successfully (2 died from sepsis in the early postoperative period). Mean age of kidney transplant recipients was 14.1 years, and 4 were male patients. The most common etiology was vesicoureteral reflux (n = 3). One kidney graft was from a deceased donor, with the rest from living related donors who were first-degree relatives of the recipients (n = 11; mother for 8 recipients and father for 3 recipients). Mean hospital stay was 4.3 days. All kidney transplant recipients were discharged successfully. CONCLUSIONS: Solid-organ transplants for young children are often complex but can be performed successfully at experienced transplant centers.

Effect of meal intake for evaluating hepatic artery by Doppler ultrasonography in liver transplants: Does fasting matter for screening hepatic artery due to hemodynamic changes in splanchnic circulation?

PURPOSE: The aim of this study is to assess the utility of fasting on Doppler ultrasonography findings of hepatic artery in liver transplants. METHODS: Liver transplant patients without vascular abnormalities were prospectively evaluated between December 2017 and January 2020. Doppler sonography was used to describe hemodynamic changes in response to a standard meal. The diameter, peak systolic velocity, blood flow, resistive index (RI) of the main hepatic artery and portal vein peak velocity were measured. RESULTS: The mean hepatic arterial diameter of 44 patients was higher in the fasting group (4.5 mm) than in the postprandial group (3.3 mm) (p < .05). The mean hepatic arterial blood flow decreased (from .276 to .127 L/min) and hepatic arterial RI increased (from .66 to .71) following meal ingestion (p < .05). Hepatic arterial velocity was significantly lower and portal venous velocity was higher after oral intake. CONCLUSION: Meal ingestion has an important effect on hepatic artery Doppler features in liver transplants. Therefore, Doppler ultrasound evaluation should be considered after appropriate fasting due to postprandial responses of liver transplant.

Stereotactic Ablative Body Radiotherapy as a Bridge to Liver Transplant for Hepatocellular Carcinoma: Preliminary Results of Baskent University Experience.

OBJECTIVES: Hepatocellular carcinoma is the most common primary liver tumor, with curative treatment options being liver transplant and resection. However, approximately 20% to 30% of patients have substantial disease progression while awaiting transplant. Here, we report our initial experience on stereotactic ablative body radiotherapy as a bridge to liver transplant for patients with hepatocellular carcinoma. MATERIALS AND METHODS: Seven patients with 9 lesions received stereotactic ablative body radiotherapy as a bridge treatment to transplant. All patients underwent radiofrequency ablation, transcatheter arterial chemoembolization, or hepatic resection before stereotactic ablative body radiotherapy. Magnetic resonance imaging was used to evaluate radiographic responses 1 month later. RESULTS: Median age of patients was 65 years (range, 63-71 years), median stereotactic ablative body radiotherapy dose was 45 Gy (range, 30-54 Gy; delivered in 3-5 fractions), and median tumor diameter was 17 mm (range, 12-30 mm). Before stereotactic ablative body radiotherapy, all patients underwent liver-directed therapies, including transcatheter arterial chemoembolization for 3 lesions, transcatheter arterial chemoembolization and radiofrequency ablation for 4 lesions, surgical resection for 1 lesion, and surgical resection plus transcatheter arterial chemoembolization for the remaining lesion. Patients showed no evidence of gastrointestinal toxicity or radiation-induced liver disease. Acute toxicity was negligible; all patients completed the treatment course. One month after stereotactic ablative body radiotherapy administration, response rates were assessed with magnetic resonance imaging, with complete responses obtained in 5 lesions (55.5%), partial responses for 2 lesions, and stable disease for 2 lesions. No disease progression was shown following stereotactic ablative body radiotherapy application. CONCLUSIONS: Stereotactic ablative body radiotherapy is an effective, safe, and tolerable bridging therapy option. Although we observed an early response after treatment, exact response rates will not be known for at least 3 months following stereotactic ablative body radiotherapy. Thus, our findings should be confirmed through additional prospective studies with longer follow-up.

Role of Interventional Radiology in the Management of Early Vascular Complications After Liver Transplant.

OBJECTIVES: A hepatic vascular complication after liver transplant is a critical situation, often resulting in graft failure and potentially leading to patient death. Early diagnosis and treatment of vascular complications can provide prolonged graft survival and prohibit further complications. This study presents our experiences with endovascular treatment during the first week after liver transplant. MATERIALS AND METHODS: Between January 2012 and February 2021, 240 liver transplants were performed, with 43 patients having early endovascular treatment (37 men; mean age 27 ± 2.9 years) at a single center. Early endovascular interventions were carried out 1 to 7 days (mean ± SD of 2.7 ± 0.24 days) after transplant. Patients with vascular complications were grouped by arterial, venous, and portal complications. In addition, arterial complications were subgrouped by occlusive (hepatic artery thrombosis) and nonocclusive (hepatic artery stenosis/splenic artery steal syndrome) complications. Patients had median follow-up of 47 ± 4 months. RESULTS: In the first week after liver transplant, vascular complications included splenic artery steal syndrome in 27 patients (62.7%), hepatic complications in 10 patients (23.2%) (7 with hepatic artery thrombosis, 3 with hepatic artery stenosis), hepatic venous outflow complications in 4 patients (9.3%), and portal vein complications in 2 patients (4.6%). Only 1 patient required revision surgery because of excessive arterial kinking; the remaining patients with arterial complications were successfully managed with multiple endovascular treatment attempts. Patients with splenic artery steal syndrome were treated by selective arterial embolization with coil devices. Resistivity index, peak systolic velocity of hepatic arteries, and portal vein maximal velocity significantly improved (P < .001). Patients with hepatic venous outflow and portal vein complications who had endovascular treatments and vascular structures maintained good results over follow-up. CONCLUSIONS: Early endovascular intervention is feasible and safe for hepatic vascular complications following liver transplant, with high success treatment rates with advances in interventional radiology.

Gender Disparity and the Relationship Between Living Donors and Recipients in Kidney Transplants in an Organ Transplant Center in Turkey.

OBJECTIVES: The literature search on kidney transplant procedures performed in Turkey showed that few publications are available about gender distribution and the relationships between living donors and recipients. Therefore, this study aimed to examine the gender distributions and the relationships between donors and recipients of living-donor kidney transplants performed in a university hospital in Ankara, Turkey. MATERIALS AND METHODS: In this study, we retrospectively analyzed the hospital records of living kidney donors (1611 cases) and all 1991 kidney recipients who underwent living-donor and deceased-donor kidney transplant procedures in a university hospital between 1985 and 2017. RESULTS: In the study hospital, the annual average number of living-donor kidney transplants increased from 19 to 49 cases (total of 1611 cases) per year during the analyzed period. Among them, 57.8% of all kidney donors were female (P < .05), whereas 74.7% of the recipients were male (P < .05). Two-thirds (60.0%; 228/380) of deceased-donor kidney recipients were male. First-degree blood relatives accounted for most of the donors, as the most common donor-recipient relation was mother to son (67.3%; 327/486; P < .05). Interspousal donation also showed a significant difference between husband to wife and vice versa (36 vs 145; P < .05). CONCLUSIONS: There was a male and young predominance among recipients and a female and middleaged predominance among donors of living kidney transplants in this hospital. It is not known whether this might be related to possible differences between males and females in demand of kidneys, to socio-cultural and gender inequalities, or to economic factors. Further research with qualitative components on gender factors should be carried out.

Relationship Between Exercise Perception With Physical Activity Level, Body Awareness, and Illness Cognition in Renal Transplant Patients: A Pilot Study.

OBJECTIVES: Transplantation offers better quality of life and long-term survival benefits. Further knowledge is needed regarding exercise in daily life of transplant recipients. Here, we investigated the relationship between exercise perception and physical activity level, body awareness, and illness cognition in renal transplant patients. MATERIALS AND METHODS: Our study included 53 renal transplant recipients (Standardized Mini-Mental Test score = 26.35 ± 1.36; age = 41.11 ± 13.52 year, body mass index = 25.96 ± 5.26 kg/m², elapsed time after transplant = 3.68 ± 1.53 year). Perceived benefits and barriers to exercise, physical activity level, body awareness, and illness cognition were assessed with the Exercise Benefits/Barriers Scale, International Physical Activity Questionnaire, Body Awareness Questionnaire, and Patient Illness Perception Questionnaire, respectively. Correlations were established with Spearman test for nonparametric data, with regression analysis used to find determinants of physical activity levels. RESULTS: We observed correlations between physical activity level and perceived benefits and barriers to exercise. There was a positive relationship between body awareness and perceived benefits and barriers to exercise and also illness cognition, with significant correlation between perceived benefits and barriers to exercise and illness cognition (P < .05). Perceived benefits and barriers to exercise (P = .006, R = 0.373, R2 = 0.139, beta = 0.373, t = 2.867, F = 8.22) were determining factors for physical activity level. CONCLUSIONS: Psychologic and physical factors, including negative emotions and body dissatisfaction, are risk factors for poor quality of life. Although it is important to increase quality of life, tools to enhance body awareness and to develop strategies to alter motor behaviors in daily living activities are needed. Treatment and assessment strategies on body awareness and illness perception should be considered, with emphasis on the importance of physical activity posttransplant.

Causes of Hemoptysis in Renal Transplant Patients.

OBJECTIVES: Hemoptysis is a symptom that can be caused by airway disease, pulmonary parenchymal disease, or pulmonary vascular disease, or it can be idiopathic. Infection is the most common cause of hemoptysis, accounting for 60% to 70% of cases. Hemoptysis is also an initial symptom of diffuse alveolar hemorrhage syndrome, although it may be absent at presentation in one-third of patients. Diffuse alveolar hemorrhage is characterized by disruption of the alveolar-capillary basement membranes because of either injury or inflammation of the arterioles, venules, or capillaries, resulting in bleeding in alveolar spaces. To date, no study in the literature has investigated the cause of hemoptysis in renal transplant patients. In this retrospective study, we aimed to investigate the causes of hemoptysis in renal recipients. MATERIALS AND METHODS: The data included in this study were obtained from 352 renal transplant patients who were consulted by the pulmonology department regarding hemoptysis between 2011 and 2017 at Baskent University. Patient medical records were reviewed for demographic, clinical, radiographic, bronchoscopic features, and microbiology data. Immunosuppressive drugs and clinical outcome data were also noted. RESULTS: This study included 352 renal transplant patients (139 male patients with mean age of 34.9 ± 7 years and 113 female patients with mean age of 31.1 ± 5 years). Hemoptysis was detected in 17 patients (4.8%),with 3 (0.85%) having massive hemoptysis as a result of diffuse alveolar hemorrhage syndrome. Fourteen of our patient group (4%) had pneumonia, and Aspergillus species was detected in 5 patients (1.4%). The only reason for diffuse alveolar hemorrhage was immunosuppressive agents, including sirolimus and mycophenolate mofetil. CONCLUSIONS: Hemoptysis is an important respiratory symptom in renal transplant patients. Although community- or hospital-acquired pneumonia may result in hemoptysis, drug-induced diffuse alveolar hemorrhage and Aspergillus infection should be considered for causes in renal transplant patients.

Treatment of biliary complications after liver transplant: results of a single center.

Biliary complications are major sources of morbidity after liver transplant due to vulnerable vascularization of the bile ducts. Biliary complications are the "Achilles' heel" of liver transplant with their high incidence, need for repeated and prolonged treatment, and potential effects on graft and patient survival. Although standardization of reconstruction techniques and improvements in immunosuppression and organ preservation have reduced the incidence of biliary complications, in early reports the morbidity rates are 50%, with related mortality rate 25% to 30%. Prophylaxis is a major issue. Although many risk factors (old donor age, marginal graft, prolonged ischemia time, living-donor liver transplant, partial liver transplant, donation after cardiac death, hepatic arterial thrombosis, organ preservation, chronic rejection, and other donor and recipient characteristics) do not directly affect biliary complications, accumulation of the factors mentioned above, should be avoided. However, no accepted standard has been established. Treatment strategy is a subject of debate. Recently, nonoperative treatment of biliary complications have been preferred for diagnosis and therapy, because percutaneous or endoscopic treatment may prevent the need for surgical intervention. In this study, we reviewed our treatment of early and late biliary complications after liver transplant.

Dermal tophus: a complication of gout in a kidney transplant recipient.

Gout is a chronic metabolic disease caused by disturbance of purine metabolism that leads to hyperuricemia. Hyperuricemia prevalence after renal transplant is reported as 19% to 84% in different studies. Tophaceous gout in renal transplant recipients is a consequence of increased hyperuricemia. Although tophus formation in skin and soft tissues is an indicator of chronic gout (also referred to as tophaceous gout), tophi may be the first sign of gout. In this study, we report a case of a 62-year-old male renal transplant recipient who had tophi as the first clinical sign of gout. After confirming gout diagnosis, cyclosporine was changed to sirolimus, and allopurinol was added to therapy to decrease uric acid levels. In conclusion, hyperuricemia is a common complication in renal transplant recipients. Presentation might be atypical, and diagnosis can be challenging.