ADCK4-Associated Glomerulopathy Causes Adolescence-Onset FSGS.

Hereditary defects of coenzyme Q10 biosynthesis cause steroid-resistant nephrotic syndrome (SRNS) as part of multiorgan involvement but may also contribute to isolated SRNS. Here, we report 26 patients from 12 families with recessive mutations in ADCK4. Mutation detection rate was 1.9% among 534 consecutively screened cases. Patients with ADCK4 mutations showed a largely renal-limited phenotype, with three subjects exhibiting occasional seizures, one subject exhibiting mild mental retardation, and one subject exhibiting retinitis pigmentosa. ADCK4 nephropathy presented during adolescence (median age, 14.1 years) with nephrotic-range proteinuria in 44% of patients and advanced CKD in 46% of patients at time of diagnosis. Renal biopsy specimens uniformly showed FSGS. Whereas 47% and 36% of patients with mutations in WT1 and NPHS2, respectively, progressed to ESRD before 10 years of age, ESRD occurred almost exclusively in the second decade of life in ADCK4 nephropathy. However, CKD progressed much faster during adolescence in ADCK4 than in WT1 and NPHS2 nephropathy, resulting in similar cumulative ESRD rates (>85% for each disorder) in the third decade of life. In conclusion, ADCK4-related glomerulopathy is an important novel differential diagnosis in adolescents with SRNS/FSGS and/or CKD of unknown origin.

[Monitoring of cytomegalovirus-specific CD4+ and CD8+ T cell responses by cytokine flow cytometry in renal transplant recipients]. / Böbrek nakil hastalarinda sitomegalovirusa özgül CD4+ ve CD8+ T hücre yanitinin sitokin akim sitometri yöntemiyle izlemi.

In spite of the improvements in the clinical management of solid organ transplant (SOT) recipients provided by immunosuppresion and universal prophylaxis, human cytomegalovirus (CMV) infections continue to be one of the most leading causes of morbidity and mortality. Cell-mediated immunity specific to CMV (CMV-CMI) plays an important role in the control of CMV replication. Therefore, monitoring of CMV-specific T-cell response can be used to predict individuals at increased risk of CMV disease. The aim of this study was to investigate the levels of CMV-specific interferon (IFN)-γ producing CD4(+) and CD8(+) T cells in kidney transplant recipients before and after the transplantation, by cytokine flow cytometry. A total of 21 kidney transplant recipients (14 male, 7 female; age range: 18-66 years, mean age: 34.5 ± 9.9) who were all CMV seropositive have been evaluated in the study. Blood samples from the patients were obtained before and at the 1(st), 3(rd) and 6(th) months after transplantation. CMV seropositive healthy kidney donors (n= 20) constituted the control group. The main stages of our procedure were as follows; isolation of peripheral blood mononuclear cells from whole blood, freezing and storing of the samples, later on thawing the samples, ex vivo stimulation of lymphocytes with pooled CMV peptides and counting CMV-specific IFN- producing CD4(+) and CD8(+) T cells by flow cytometry following surface and intracellular cytokine staining. Monitoring of the viral load (CMV-DNA) was performed in 10 days intervals in the first 3 months followed by 3 week intervals until 6 months using COBAS AmpliPrep/COBAS TaqMan CMV test system (Roche Diagnostics, USA). The frequencies of pretransplant CMV-specific IFN-γ producing CD8(+) T cells in patient (3.53 ± 4.35/µl) and control (4.52 ± 5.17/µl) groups were not statistically different (p= 0.266). The difference between the number of virus-specific CD4(+) T cells in patients (8.84 ± 9.56/µl) and those in the control group (8.23 ± 11.98/µl) was at the borderline of significance (p= 0.057). The age and gender of the patients and type of antiviral prophylaxis protocols [valgancyclovir (n= 4); valacyclovir (n= 17)] did not have any significant effect on CMV-CMI (p> 0.05). Similarly, induction therapy administered to four patients did not show any effect on CMV-CMI (p> 0.05). CMV-specific immune responses of patients who received different immunosuppression protocols [tacrolimus + mycophenolate mofetil (MMF) + steroid (n= 17); cyclosporine + MMF + steroid (n= 2); mTOR inhibitor + MMF + steroid (n= 2)] were not different (p> 0.05). The number of CMV-specific CD4(+) T cells in all patients were significantly decreased in the 3rd month compared to the 1st month after the transplantation (p=0.003), indicating a relationship with the period of immunosuppressive therapy. In one of the patients who did not have CMV-specific CD4+ T-cell response but had cytotoxic T-cells (CD8(+) T= 0.6%) before transplantation, CD4(+) T-cell response have developed during monitorization (1.4%, 1.5% and 0.5% in 1st, 3rd and 6th months, respectively), and no viral reactivation was detected. Out of the two patients who had no CD4(+) and CD8(+) T cell response in the 3rd month, one of them developed low level viremia (150 copies/ml) in the 6th month. In this patient the level of CMV-CMI in the 6th month (CD4(+)T + CD8(+)T= 0.9%), have reached higher values than the values obtained before the transplantation (CD4(+) T + CD8(+) T= 0.5%). The viremia was cleared spontaneously in this patient and no antiviral therapy was required. In conclusion, our results suggested that pretransplant and posttransplant monitoring of CMV-specific T-cell responses might be helpful as well as viral load in the clinical management of CMV infection in SOT patients.

Effect of age on the outcome of renal transplantation: A single-center experience.

OBJECTIVES: To analyze the effects of old age on renal transplantation (Tx) results and graft survival, and compared elderly patient population with the young patients. METHODS: A total of 1946 renal transplant were performed from 1537 living and 409 cadaveric donors between 2003 and 2014. The recipients were divided into two groups according to their age at the time of transplantation. The young age group consisted of 18-59-year-old, and the elderly group consisted of the ones ≥ 60 years. RESULTS: Acute rejection was seen in 19.5% of the young age group while this rate was 16.7% in the old age group (p=0.535). DGF was seen in 6.3% of the young age group, and in 13.5% of the old age group (p<0.001). Analysis of the overall survival rates demonstrated that 1.6% of the patients in the young age group and 6.8% of the patients in the old age groups died (p=0.003). CONCLUSIONS: Renal transplant had high graft survival rates in the elderly as in the young patients. However, the risks for complications were higher in the older age group compared to the younger age group. Thus, it is important to make a careful selection among elderly candidates for renal transplantation.

A retrospective analysis of pregnancy outcomes after kidney transplantation in a single center.

BACKGROUND: We reported pregnancy outcomes after kidney transplantation in a single transplant center. METHODS: We reviewed the perinatal outcomes of female kidney transplant patients of reproductive age (18-40 years) from 1987 to 2011. RESULTS: A total of 246 patients were reviewed. Of these, 43 women registered a pregnancy following kidney transplantation. The mean patient age was 31.3 ± 4.2 years (range 24-40). The mean transplant-conception interval was 35.9 ± 12.6 months (range 24-120); 9 patients had a cadaveric allograft. The human leukocyte antigen match was ≥3/6 for 34 patients. The rate of live births was 29/43 (67.4%), miscarriage 10/43 (23.2%), preterm delivery 7/29 (24.1%), preeclampsia 5/29 (17.2%), and intrauterine growth retardation 2/29 (6.9%). Overall, 3/29 patients (10.3%) received a blood transfusion during pregnancy due to persistent symptomatic anemia, despite iron replacement and erythropoietin therapy; 24 patients (82%) had a cesarean section delivery; 3 patients had kidney rejection during pregnancy, with 2 occurring during the 6th postpartum month. CONCLUSION: Pregnancy should be considered a high risk in renal transplant recipients, necessitating close follow-up.

Epstein-Barr virus infection in children with renal transplantation: 17 years experience at a single center.

OBJECTIVES: The aim of this study was to detect the frequency, time of occurrence, management and outcome of Epstein-Barr virus (EBV) infection and related complications in pediatric renal transplant recipients. METHODS: Pediatric renal allograft recipients transplanted between August 1994 and December 2011 at our hospital was evaluated retrospectively. The patients were divided into two groups; Groups 1 and 2 were composed of patients transplanted before and after November 2007, respectively, when plasma EBV DNA levels were periodically measured. RESULTS: The study included 166 children, 89 (53.6%) boys, with a mean age of 12.2 ± 3.8 years. Prior to transplantation, 144 patients (86.7%) were EBV seropositive. Within a median follow-up period of 36 months, 11 of 22 seronegative children (50%) developed primary EBV infection. EBV reactivation was observed in 23 of 144 children (15.9%). Two patients with primary infection developed post-transplant lymphoproliferative disorder, one of whom died. Elevated serum creatinine levels or graft loss were not observed in any patient with EBV reactivation. CONCLUSIONS: EBV DNA monitoring by PCR in high-risk pediatric renal transplant recipients will provide early diagnosis and treatment of EBV infections.

Surgical correction of vesico-ureteric reflux for recurrent febrile urinary tract infections after kidney transplantation.

OBJECTIVE: To evaluate the outcome of anti-reflux revision surgery in patients diagnosed with at least a grade 3 reflux at voiding cysto-urethrography in patients with recurrent urinary tract infection (UTI) after renal transplantation. PATIENTS AND METHODS: We identified 60 patients with a diagnosis of recurrent febrile UTI and post-transplantation vesico-ureteric reflux (VUR) who underwent open surgical correction of reflux. Patient characteristics, including the aetiology of end-stage renal disease, age, time to VUR correction, type of VUR correction, serum creatinine levels, and number of UTIs before and after correction were documented. RESULTS: The median (range) age of the patients was 31.5 (9-65) years. A total of 30 patients underwent uretero-ureterostomy or pyelo-ureterostomy and 30 underwent extravesical or intravesical ureteric reimplantation. The median (range) creatinine levels before and after correction were 1.5 (0.8-4.5) mg/dL and 1.3 (0.7-4.5) mg/dL (P<0.05), respectively. The median (range) number of UTI episodes reported before the correction surgery was 4 (3-12), whereas number of UTI episodes after the surgery was 1 (0-12), the difference being significant (P<0.05). CONCLUSIONS: Open surgical correction of post-transplant VUR is an effective and safe method of decreasing UTI episodes and stopping reflux. Surgical correction of reflux may prolong the life of the renal graft.

Circulating endothelial cells in pediatric renal transplant recipients.

BACKGROUND: An increase in the number of circulating endothelial cells (CEC) indicates endothelial damage and the risk of cardiovascular disease. The aim of our study was to investigate the association of CEC with various clinical parameters in pediatric renal transplant recipients. METHODS: CEC, defined as CD45(-)CD146(+), were enumerated by flow cytometry from the peripheral blood of 50 pediatric renal transplant recipients and 20 healthy controls. Clinical parameters, including renal function tests, fasting blood glucose, serum cholesterol and triglyceride, cyclosporine A (CsA) (trough and 2nd-hour) and tacrolimus (tac) trough blood levels and their association with CEC numbers were analyzed. RESULTS: CEC numbers of patients were higher than those of controls (respectively, 128 ± 89 cells/ml (42-468 cells/ml), 82 ± 33 cells/ml (32-137 cells/ml), p = 0.024). There was a statistically significant negative correlation between CEC numbers and glomerular filtration rate (GFR) (r = -0.300, p = 0.012). There was also a statistically positive association between CEC numbers and transplant duration as well as cyclosporine trough level (respectively, r = 0.397, p = 0.004, r = 0.714, p = 0.004). CEC numbers in patients on tac and CsA were similar (p = 0.716). CONCLUSIONS: Our results demonstrate that renal transplant recipients with high CsA trough blood level, longer transplant duration, and lower GFR, are at greater risk of developing endothelial damage.

[BK virus infections in pediatric kidney transplant recipients]. / Pediatrik renal transplant alicilarinda BK virus enfeksiyonlari

Primary BK virus (BKV) infections acquired mainly during childhood are usually asymptomatic. Several studies revealed its seroprevalence in adult population as high as 90% worldwide. Following primary infection, virus persists as latent infection in the urogenital tract. In renal transplant recipients, primary infection and reactivations affect 10% of patients and without treatment, more than half of these patients lose their grafts. The only way of preventing graft loss due to BKV nephropathy (BKVN), seems to monitor BKV infection after transplantation and to diagnose patients developing BKVN during the early period and treat them accordingly. In this study, we analyzed BKV presence in plasma and urine samples with real-time PCR method and evaluated the renal biopsies of pediatric renal transplant recipients after transplantation, retrospectively. A total of 142 children (63 female, 79 male; mean age: 11.7 ± 3.9 years) who had renal transplantation in Akdeniz University Medical Faculty, Antalya, Turkey, between February 2006 and April 2011 were enrolled in the study. After transplantation, peripheral blood and urine samples were collected bi-weekly for the first three months, monthly till the sixth month and every three months thereafter. BKV DNA was additionally screened in patients with unexplained rise in serum creatinine or in patients receiving anti-rejection therapy. In any plasma positivity or during the BKVN therapy, BKV DNA analysis was done bi-weekly. After DNA extraction by automated system, an 83 base pair fragment in VP1 region was amplified. Signal detection for the target region was performed with a TaqMan probe dual-labelled at the 5' end with 6-carboxyfluorescein (FAM) and the 3' end with 6-carboxytetramethylrhodamine (TAMRA). Histopathological examinations of renal biopsies were done with routine histological stains and immunohistochemical staining with monoclonal antibodies directed to SV40 antigen. From 2171 plasma and 1995 urine samples without PCR inhibitors, 442 (20%) (range: 300-4.5 x 10(7) copies/ml; mean: 2.0 x 10(5) ± 2.2 x 10(6) copies/ml) and 800 (40.1%) (range: 300-3 x 10(12) copies/ml; mean: 5.9 x 10(9) ± 1.1 x 10(11) copies/ml) were found positive for BKV DNA, respectively. For 114 (80.3%) patients, at least one urine sample was positive and more than half of those patients (68/114, 59.6%) had viremia. Of the patients, 19.7% (28/142) had viral DNA above 10(4) copies/ml, which was choosen as a cut-off value for its high positive predictive value for BKVN. For all these 28 patients, prior to renal biopsy, immunosupressive treatment was decreased. Cidofovir and/or leflunomid were initiated to nine patients who did not respond to lowered immunosupressive therapy and eight of them had renal biopsy for the confirmation of BKVN. All renal biopsy results were compatible with BKVN. From these nine patients who were receiving cidofovir and/or leflunomid, two lost their grafts because of BKVN. Since viruria is frequently encountered and the viral load is usually in low quantities and transient, it is more appropriate to use blood samples for screening programmes after renal transplantation. The efficacy of antiviral treatment in BKVN could not be evaluated since it was only applied in patients non-responding to lowered immunosuppressive therapy and had decreased renal functions. Multicenter prospective studies are required to enlighten this important issue. Early diagnosis with close monitoring of renal function and viremia, seems to be the most effective way for controlling BKVN.

Immediate Extubation in the Operating Room Following Pediatric Liver Transplantation: A Retrospective Cohort Study.

BACKGROUND: Although immediate extubation in the operating room following pediatric liver transplantation can be safe and beneficial for select patients, many surgeons and anesthesiologists are still cautious. The study aimed to evaluate the safety and efficiency of immediate extubation in the operating room following pediatric liver transplantation. METHODS: Sixty-four pediatric liver transplant recipients were included in this retrospective study. Patients were divided into 2 groups: immediate extubation (IE) (those who were extubated in the operating room) and delayed extubation (DE) (those who were extubated in the intensive care unit). Preoperative, intraoperative, and postoperative variables were recorded. RESULTS: Although a total of 19 (29.7%) patients were extubated in the pediatric intensive care unit (group DE), 45 (70.3%) were extubated in the operating room at the end of surgery (group IE). The use of fresh frozen plasma and platelets was statistically higher in group DE (P = .017 and P = .002, respectively). Duration of anesthesia and length of stay in the pediatric intensive care unit was statistically longer in group DE (P = .020 and P = .0001, respectively). Three (15.8%) patients required reintubation in group DE and 2 (4.4%) in group IE. Hospital stay was statistically longer in group DE (P = .012). CONCLUSIONS: The current study demonstrated that immediate extubation in the operating room after surgery for pediatric patients who have undergone liver transplantation was safe. The duration of anesthesia and the intraoperative use of blood products such as platelet and fresh frozen plasma can effectively decide immediate extubation.

Is the Presence of 2 Renal Allograft Arteries Associated with Adverse Outcomes in Live Donor Kidney Transplantation?

OBJECTIVE: Although it was postulated that renal grafts with multiple arteries could lead to unfavorable recipient outcomes, this subject remains controversial. This study aimed to compare the outcomes of recipients receiving renal allografts with a single artery with those receiving renal grafts with two arteries. MATERIALS AND METHODS: Adult patients who received live donor kidney transplantation in our center between January 2020 and October 2021 were included. Data including age, gender, body mass index, renal allograft side, pre-kidney transplantation dialysis status, human leukocyte antigen mismatch number, warm ischemia time, the number of renal allograft arteries (single/double), complications, duration of hospitalization, postoperative creatinine levels, glomerular filtration rates, early graft rejection, graft loss, and mortality were collected. Subsequently, patients who received single-artery renal allografts were compared with those who received double-artery renal allografts. RESULTS: Overall, 139 recipients were included. The mean recipient age was 43.73 ± 13.03 (21-69). While 103 recipients were male, 36 were female. The comparison between the 2 groups revealed that mean ischemia time was significantly longer in the double-artery than in the single-artery group (48.0 vs. 31.2 minutes) (P=.00). In addition, the single-artery group had significantly lower postoperative day 1 and day 30 mean serum creatinine levels. Also, the mean postoperative day 1 glomerular filtration rates were significantly higher in the single-artery group than in the double-artery group. However, the 2 groups were similar concerning the glomerular filtration rates measured at other times. On the other hand, there was no difference between the 2 groups regarding duration of hospitalization, surgical complication, early graft rejection, graft loss, and mortality rates. CONCLUSION: The presence of 2 renal allograft arteries does not have adverse effects on the postoperative parameters of the kidney transplantation recipients, including graft function, duration of hospitalization, surgical complication, early graft rejection, graft loss, and mortality rates.

Digital evaluation of the muscle functions of the lower extremities among inguinal hernia patients treated using three different surgical techniques: a prospective randomized study.

PURPOSE: An inguinal hernia is a common pathology that can be treated using several different surgical procedures. Although there have been many studies comparing the clinical results of these techniques, there has so far been no digital analysis of the alterations developing secondary to pain with regard to the muscle functions of the lower extremities. This prospective randomized trial was designed to compare this aspect for subjects treated using the laparoscopic techniques and those treated using the conventional method. METHODS: A total of 75 patients, 25 of whom who had undergone hernia repair using the total extraperitoneal technique, 25 of whom who had undergone repair using the transabdominal preperitoneal technique, and 25 who had undergone repair using the Prolene mesh graft technique, were evaluated preoperatively and on the third postoperative day by isometric and isokinetic measurements, the visual analog score (VAS), the necessity of postoperative analgesia, complications, and the time that had elapsed before returning to work, and these results were recorded. RESULTS: Hernia repair using the conventional method led to an average of 3 times more muscle function loss compared with the laparoscopic techniques, and this difference was shown to be statistically significant. The VAS, postoperative complications, and time elapsed before returning to work were lower for laparoscopic surgeries and also were compatible with the findings described in the previous literature. CONCLUSIONS: Use of a digital environment with numerical parameters and measurements recorded using a dynamometer demonstrated that in the early postoperative period and on the third postoperative day, open surgery causes more functional loss in the lower extremities than laparoscopic methods. Therefore, surgeons should use laparoscopic methods whenever possible to reduce both pain and loss of muscle function.

Liver transplantation in hepatic myelopathy.

Hepatic myelopathy (HMy) is a rare neurological complication of liver cirrhosis that involves spastic paraplegia caused by lateral cord demyelination especially due to the accumulation of some metabolites such as ammonia and manganese. We report a young adult woman presenting with spasticity and paraparesis in extremities after intrahepatic portosystemic shunting (TIPS) application and underwent deceased liver transplantation (LT). A 39-year-old woman underwent deceased LT because of cryptogenic liver cirrhosis. She underwent a TIPS procedure 5 years ago. After that, hepatic encephalopathy and spasticity appeared. She was on the waiting list for 3 years. Neurological findings after LT significantly decreased, but did not return to normal. After the emergence of neurological findings, the earlier LT can provide improvement in neurological findings.

The role of intraoperative ultrasonography in detection of hepatic vein variations in living donor liver transplantation.

BACKGROUND: With advances in surgical techniques and immunosuppression, liver transplantation has become the most effective treatment of acute and chronic liver failures. Evaluation of vascular anatomy and detection of hepatic vascular variations prior to surgery, especially transplantation surgery, can help reduce complications in both the donor and the recipient. Intraoperative ultrasonography (IOUS) is known to be beneficial during planning of the transplantation surgery, and can help direct the surgery itself. OBJECTIVES: To our knowledge, there are no existing studies that evaluate the number and diameter of segment 5 and 8 branches that need to be anastomosed with IOUS. PATIENTS AND METHODS: In this study, considering surgical anatomical evaluation as the gold standard, IOUS findings were compared to computed tomography angiography (CTA) findings. 40 patients were included in the study. RESULTS: The average diameters of segment 8 branches that were anastomosed and not anastomosed were significantly different when measured by IOUS (p = 0.016); however, no such statistically significant difference was found in measurements made with CTA (p = 0.89). CONCLUSION: CTA is superior to IOUS in detecting segment 5 and 8 veins draining into the middle hepatic vein. However, IOUS is more accurate in predicting which vessels are going to be anastomosed. For a complete and accurate assessment, both imaging modalities should be used to complement each other, and their respective advantages and disadvantages should be known.

Correlation Between the Mayo Adhesive Probability Score and the Operative Time in Laparoscopic Donor Nephrectomy.

BACKGROUND: Adherent perinephric fat (APF) is a known risk factor of surgical difficulty during laparoscopic donor nephrectomy (LDN). The Mayo Adhesive Probability (MAP) score predicts APF accurately. The aim of this study is to identify the association between MAP score and operative time in LDN. METHODS: We retrospectively evaluated 154 kidney donors who underwent surgery from December 2017 to December 2019 at Istanbul Aydin University Hospital and Istinye University Hospital. All of the operations were done by 3 senior surgeons by a fully laparoscopic method. The MAP score was derived from computed tomography scans by 1 blinded reader. Demographic data, body mass index (BMI), MAP score, side selection, estimated glomerular filtration rate (eGFR), number of arteries and veins, operative time, hospital stay, and complications are recorded. Single and multiple variable analyses were used to evaluate the correlation between operative time and MAP score, BMI, side selection, and number of vascular structures. RESULTS: A total of 154 patients (79 men, 75 women) with a mean age of 44.4 ± 12.72 were included in this study. None of the cases were converted to open nephrectomy. There were no major complications. Mean BMI was 27.59 ± 4.32 kg/m2, mean MAP score was 0.69 ± 1.15, and mean operative time was 40.25 ± 9.81 minutes. Although mean BMI was higher in women (28.19 ± 4.52 vs 27.03 ± 4.07; P < .05), mean MAP score was lower than in men (0.35 ± 0.86 vs 1.03 ± 1.29; P < .001). Older age, higher BMI, higher MAP score, and presence of multiple renal arteries were associated with longer operative time of LDN. The MAP score was associated with older age, male sex and higher BMI. CONCLUSIONS: This study showed that different risk factors can affect operative time in LDN. The MAP score was significantly associated with longer operative time, especially in men, so it can be useful for predicting surgical difficulty in kidney donors.

Results of Using the Cystic Duct for Reconstruction of One of the Multiple Bile Ducts in Right Lobe Living Donor Liver Transplantation.

BACKGROUND: In right-lobe liver grafts, variations in the biliary tree anatomy can result in multiple bile duct orifices. We present our experience of 10 patients in which biliary reconstruction was performed with the cystic duct for 1 of the anastomoses with 2 separated ducts. Also, we investigated whether the bile duct anastomosis technique, number of bile duct anastomoses, and use of biliary stents affect the rate of biliary complications. METHODS: We evaluated patients who underwent right-lobe living donor liver transplantation (LDLT) at Istinye University Hospital and Istanbul Aydin University Hospital between December 2017 and June 2020. The patients were divided into 4 groups: duct-to-duct (D-D), duct-to-sheath, double duct-to-duct, and duct-to-duct plus cystic duct-to-duct. Biliary complication rates were compared among these 4 groups, between single- and double-duct groups, and between stent (+) and stent (-) groups. RESULTS: Ninety-three patients who underwent right-lobe LDLT (60 men, 33 women) with a mean age of 51 ± 13 years were included. Mean follow-up time was 18.5 ± 8.3 months. The overall biliary complication rate was 17.2% for all patients, 12.1% for the D-D (single-duct) group (33 patients), 16.1% for the duct-to-sheath group (31 patients), 26.3% for the double duct-to-duct group (19 patients), 20% for the duct-to-duct plus cystic duct-to-duct group (10 patients), 20% for the double-duct group (60 patients), 14.5% for the stent (+) group (69 patients), and 25% for the stent (-) group (24 patients). There were no significant differences among these groups in terms of biliary complication rates. Bile stricture occurred in only 1 cystic duct anastomosis (10%), and no bile leakage was observed. CONCLUSIONS: Multiple D-D biliary reconstruction using the cystic duct with external drainage tubes is feasible and safe for LDLT.

Graft Survival in Patients With Lower Urinary Tract Dysfunction.

OBJECTIVES: We aimed to the determine urinary tract infection and graft survival rates in pediatric renal transplant recipients with lower urinary tract dysfunction with particular focus on neurogenic bladder, posterior urethral valve, and vesicoureteral reflux nephropathy. MATERIALS AND METHODS: Patients were grouped according to primary diseases as those with and without lower urinary tract dysfunction. Urinary tract infections during year 1 posttransplant were investigated. Estimated glomerular filtration rate was calculated using Schwartz formula. RESULTS: Our study investigated 133 kidney transplant recipients. Lower urinary tract dysfunction was found in 58 patients (43.6%): 25 with posterior urethral valve, 24 with vesicoureteral reflux nephropathy, and 9 with neurogenic bladder. Rates of posttransplant urinary tract infection were higher in patients with lower urinary tract dysfunction than in those without during both the first 6 months posttransplant (24.6% vs 10.8%; P = .037) and between posttransplant months 6 and 12 (24.6% vs 8.2%; P = .01). Patients with neurogenic bladder had the highest rate of urinary tract infections, and their estimated glomerular filtrations rates were lower compared with patients with posterior urethral valve and vesicoureteral reflux nephropathy at month 6 and years 1, 2, and 5 posttransplant (P < .001). The 5-year graft survival rates of patients without lower urinary tract dysfunction and those with vesicoureteral reflux nephropathy were similar (51.3% vs 51.6%; P = .891). CONCLUSIONS: Graft survival rates of patients with posterior urethral valve and vesicoureteral reflux nephropathy were similar to those shown in patients without lower urinary system dysfunction; however, patients with neurogenic bladder had worse graft survival and urinary tract infection rates.

Assessment of sleep pattern and quality before and after liver transplantation using different methods.

BACKGROUND/AIMS: Sleep disorders (SDs) are frequently seen in patients with liver cirrhosis. Polysomnography (PSG), actigraphy, and electroencephalogram (EEG) are the common objective methods to diagnose SDs. The most commonly used subjective methods are the Pittsburgh sleep quality index (PSQI) and Epworth sleepiness scale (ESS). We aimed to evaluate the effect of liver transplantation (LTx) on SDs using a combination of objective (PSG and EEG) and subjective (PSQI and ESS) methods. MATERIALS AND METHODS: A total of 18 patients with cirrhosis on an LTx waiting list were included in this study. Patient clinical status and biochemical parameters were evaluated. All patients completed the validated Turkish forms of the PSQI and ESS before and 9 months after LTx. All patients underwent EEG and PSG before and 9 months after LTx. RESULTS: In total, 18 patients with liver cirrhosis (men: 12; 66.7%, mean age: 53.22±10.43 years) were included in this study. Pretransplant mean PSQI and ESS scores were 8.4±3.11 and 7.28±3.89, respectively; 9-month posttransplant mean PSQI and ESS scores were 4.5±2.8 and 4.72±2.91 (p<0.01), respectively. Before transplantation, metabolic encephalopathy was detected in 6 patients by EEG, whereas metabolic encephalopathy was detected in only 1 patient posttransplant. Posttransplantation PSG sleep duration (all stages) increased relative to pretransplant PSG values. Sleep latency and rapid eye movement latency were found to be reduced compared to the pretransplant values. CONCLUSION: This pilot study compared SDs in patients with pre- and post-LTx by combining the subjective and objective methods. Significant SD improvements were found at the 9th month.

The effect of pentoxifylline on oxidative stress in CO2 pneumoperitoneum.

BACKGROUND: Carbon dioxide (CO(2)) pneumoperitoneum induces peritoneal oxidative stress. This experimental, randomized, controlled study was designed to investigate the effect of pentoxifylline on oxidative stress induced by CO(2 )pneumoperitoneum. METHODS: For this study, 36 Swiss albino rats were randomized into three groups. Arteria, vena femoralis, and peritoneal cavity were cannulated after anesthesia. The arterial pH, partial arterial oxygen pressure (PaO(2)), venous PO(2), arterial and venous PO(2) difference (P((a-v))O(2)), serum aspartate aminotransferase (AST), serum alanine aminotransferase (ALT), and thiobarbituric acid-reactive substances (TBARS) were studied at the end of the first and second hours in group 1 (control). In group 2, 1 cc isotonic NaCl was injected into peritoneal cavity and then CO(2) pneumoperitoneum was established. At the end of the first hour of insufflation and one hour after desufflation, the same parameters as in group 1 were studied. In group 3, the CO(2) pneumoperitoneum plus pentoxifylline group, all procedures as in group 2 were repeated, with the exception of pentoxifylline (50 mg/kg) injected in place of saline. RESULTS: At the end of the first hour, P((a-v))O(2 )value in group 2 was significantly less than in the control group (group 1) and group 3 (p \ 0.05). There were no significant differences in PaO(2, )pH, AST, and ALT values between groups (p [ 0.05). TBARS level in group 1 was significantly lower than in the other groups, but there was no significant difference in TBARS level between groups 2 and 3. At the end of the second hour, TBARS level in group 3 was significantly lower than in group 2 (p \ 0.05). CONCLUSIONS: Pentoxifylline may reduce the oxidative injury following laparoscopic procedures.

Renal Hilus Ligation With Single Stapler in Laparoscopic Donor Nephrectomy.

BACKGROUND: Ligation of renal hilus is the most important stage of laparoscopic donor nephrectomy. Laparoscopic staplers are securely used for renal pedicle control. We present our donor nephrectomy cases in which we used 1 stapler for renal artery and vein ligation. METHODS: Demographic data, number of arteries and veins, ligation types, operation time, and complication rates are recorded. RESULTS: One hundred twenty laparoscopic donor nephrectomy cases who were operated between December 2017 and August 2018 in Istinye University Hospital and Istanbul Aydin University Hospital were retrospectively evaluated. All of the operations were done by 2 surgeons with a fully laparoscopic method. None of the cases were converted to open nephrectomy. There was 1 renal artery in 110 (91.7%) cases, 2 renal arteries in 9 (7.5%) cases, and 3 arteries in 1 (0.8%) case. Renal artery and vein were ligated with single stapler in 115 (95.8%) cases. Double stapler was used in 5 (4.2%) patients. There were no major complications for donors and no implantation problems for grafts. DISCUSSION: Laparoscopic donor nephrectomy is the most used technique for living donor operations. Vascular stapler is securely used for renal artery and vein ligation with high costs. Two or, due to the number of vessels, sometimes 3 staplers are used in the standard technique. In our study, the operation was finished securely in 95.8% of the patients with single stapler use. Single stapler use for ligating renal hilus is safe in kidneys even with suitable multiple arteries and veins in laparoscopic donor nephrectomy.

The effect of different crystalloid solutions on acid-base balance and early kidney function after kidney transplantation.

BACKGROUND: This study aimed to quantify changes in acid-base balance, potassium and lactate levels as a function of administration of different crystalloid solutions during kidney transplantation, and to determine the ideal fluid for such patients. METHODS: In this double-blind study, patients were randomized to three groups (n = 30 each) to receive either normal saline, lactated Ringer's, or Plasmalyte, all at 20-30 mL x kg(-1) x h(-1). Arterial blood analyses were performed before induction of anesthesia, and at 30-min intervals during surgery, and total IV fluids recorded. Urine volume, serum creatinine and BUN, and creatinine clearance were recorded on postoperative days 1, 2, 3, and 7. RESULTS: There was a statistically significant decrease in pH (7.44 +/- 0.50 vs 7.36 +/- 0.05), base excess (0.4 +/- 3.1 vs -4.3 +/- 2.1), and a significant increase in serum chloride (104 +/- 2 vs 125 +/- 3 mM/L) in patients receiving saline during surgery. Lactate levels increased significantly in patients who received Ringer's lactate (0.48 +/- 0.29 vs 1.95 +/- 0.48). No significant changes in acid-base measures or lactate levels occurred in patients who received Plasmalyte. Potassium levels were not significantly changed in any group. CONCLUSIONS: All three crystalloid solutions can be safely used during uncomplicated, short-duration renal transplants; however, the best metabolic profile is maintained in patients who receive Plasmalyte.