Vascular access for haemodialysis in patients with central vein thrombosis.

OBJECTIVES: Dialysis-dependent patients often have central venous drainage complications. In patients with functioning arm arteriovenous fistula, this may result in venous hypertension, arm oedema and vascular access failure. Percutaneous angioplasty and stent implantation might be inadequate to resolve these issues. In these cases, new access can potentially be created with anastomosis to the subclavian vein, iliac vein or vena cava or by making a veno-venous graft to bypass the thrombosis. The aim of this study was to assess the utility of unusual bypasses in vascular access in patients with the central vein thrombosis. MATERIALS: A total of 49 patients were treated. The mean number of previous vascular access surgery procedures was 7.6 (3-17). We performed 19 axillo-iliac, 14 axillo-axillary bypasses and 16 conduits from the arm fistula to the jugular (nine conduits) or subclavian (seven conduits) vein for haemodialysis purposes. RESULTS: All fistulas except one were used for haemodialysis. One patient died before the first use of the fistula. At 12 months, the primary, primary assisted and secondary patency rates were 85.4%, 89.6% and 95.8%, respectively. The follow-up period ranged from 1 to 84 months. CONCLUSION: Unusual grafts are an efficient option as a permanent vascular access for haemodialysis purposes in patients with central vein occlusion.

Renal artery aneurysms: presentation of five cases.

We are presenting clinical characteristics, management and follow-up of five consecutive patients with renal artery aneurysm. Renal artery aneurysms are relatively uncommon, they rarely give rise to clinical manifestations and they are usually found incidentally. However with the introduction of Doppler ultrasound, computed tomography (CT) and magnetic resonance (MR) imaging, the diagnosis of renal artery aneurysms became more frequent.

Low molecular weight heparin treatment decreases MMP-9 plasma activity in patients with abdominal aortic aneurysm.

Large abdominal aortic aneurysms (AAAs) are associated with coagulation abnormalities, which are significantly reduced by low molecular weight heparin (LMWH). Considering anti-inflammatory properties of heparin we verified, whether LMWH influences MMP-2/-9 in AAA patients. The study involved 26 AAA individuals, 10 patients with coagulation abnormalities received LMWH and 16 were a control group. The plasma activity of MMP-2/-9 was measured using zymography. We found that, in addition to the reduction of coagulation abnormalities, LMWH treatment was associated with the decreased MMP-9 but not MMP-2 activity. Therefore, LMWH use could be considered as a valuable pretreatment before an elective aneurysm repair.

Serum 1-84 and 7-84 parathyroid hormone concentrations and bone in patients with primary hyperparathyroidism.

BACKGROUND AND AIMS: Parathyroid hormone (PTH) acts on bone as both anabolic and catabolic factor. It includes two fractions: 1-84 (cyclase activating PTH, CAP) which increases bone turnover and serum calcium, and 7-84 (cyclase inactivating PTH, CIP) acting the opposite way. The aim of this study was to establish whether bone mineral density (BMD) and turnover in patients' primary hyperparathyroidism (HPT) are dependent on CAP and CIP concentrations. PATIENTS/METHODS: Thirty-one patients with HPT and 29 appropriately matched controls were examined. Parameters of calcium-phosphate homeostasis and BMD were estimated. RESULTS: BMD of radius shaft was lower in patients with HPT as compared with controls, whereas BMD of spine and ultradistal radius were similar. Serum calcium, bone alkaline phosphatase, total PTH, 1-84 PTH, and 7-84 PTH were higher in HPT patients, whereas serum phosphate was lower and beta cross-laps similar. Both total PTH and CAP correlated significantly with BMD of radius shaft and serum calcium concentration, but not with other examined parameters. CONCLUSION: Total and 1-84 PTH are similarly associated with examined parameters in patients with HPT. Thus, determination of serum CAP concentration does not seem to have advantages over total PTH with regard to bone mineral density and bone turnover assessment in those patients.

Carbon monoxide may reduce ischemia reperfusion injury: a case report of complicated kidney transplantation from a carbon monoxide poisoned donor.

Carbon monoxide (CO), well known from clinical observation to be a deadly poisoning gas, in many animal experiments has revealed a beneficial effect to diminish ischemia/reperfusion injury and rejection of transplanted organs. Data on clinical transplantation of organs retrieved from poisoned persons are limited and discordant; some authors were reported good results, whereas others described high complication rates including death. We herein have described a case of organ transplantation retrieved from a CO-poisoned donor. Warm ischemia during the transplantation procedure was prolonged to 100 minutes, but no complications were observed in the posttransplant course. This report may represent CO preconditioning in clinical transplantation.

Insulin resistance in kidney allograft recipients treated with calcineurin inhibitors.

BACKGROUND: Post-transplant diabetes mellitus (PTDM) is one of the main complications observed in patients after organ transplantation. The incidence of PTDM in transplant recipients is about 9 times higher than in general population. The reported incidence of PTDM varied throughout the years due to different diagnostic criteria of diabetes mellitus. Nowadays the rate of PTDM amounts to 3-19%. MATERIALS/METHODS: 1270 patients after kidney transplantation, who remained under medical care in the outpatient service at the Transplantation Institute in Warsaw, were taken into consideration. The investigated group comprised 207 patients. 133 of them developed DM that constitutes the incidence of PTDM at 10.5%. RESULTS: In the present study several risk factors that are important for PTDM development were observed: male gender, HLA A3, family history of DM, increased body weight (rather than BMI only), tacrolimus--based immunosuppressive regimen, early hyperglycemia. Patients with PTDM developed hypertension more frequently, had higher serum triglycerides levels in the period before the onset of diabetes. The rate of acute rejection episodes in this group was higher compared with the nondiabetic transplant controls. The PTDM group presented with worse graft function and higher levels of proteinuria in 1-year observation. Tacrolimus--based therapy led to higher peripheral insulin resistance and hyperinsulinemia in comparison to cyclosporine--based regimen. CONCLUSIONS: The proper management of the above described risk factors and the right treatment of PTDM may considerably influence life expectancy rate and quality of life in transplanted patients.

C4d complement split product in diagnosis of immunological activity of chronic allograft nephropathy.

INTRODUCTION: Activation of the humoral branch of the immunological response is currently believed to play an important role in pathogenesis of chronic allograft nephropathy. The impact of humoral alloreactivity, indicated by the presence of C4d deposits in peritubular capillaries of a renal allograft, on the development of chronic allograft nephropathy is a significant problem in transplantation. The aim of the study was to assess and correlate C4d expression in patients with chronic allograft nephropathy, with clinical and morphological variables, as well as to assess the impact of a change in immunosuppression regimen on posttransplant course and renal allograft morphology. PATIENTS AND METHODS: Twenty-six patients with chronic allograft nephropathy underwent biopsies to correlate C4d expression with clinical parameters and morphological findings. In all patients azathioprine was replaced with mycophenolate mofetil with additional CsA dose reduction in 12 patients. After 1 year, 14 protocol biopsies were performed. RESULTS: The frequency of C4d peritubular capillary deposition among patients with chronic allograft nephropathy was 30%. C4d expression appeared later after transplantation, was correlated with chronic allograft glomerulopathy and proteinuria but not other clinical or histological variables. C4d deposits displayed no independent impact on serum creatinine level. Proteinuria was significantly more reduced in the C4d(+) group. Progression of chronic morphological changes was significantly accelerated in the C4d(+) group. CONCLUSION: C4d peritubular capillary expression did not differentiate patients after immunosuppression enhancement, but it predisposed to progression of chronic morphological findings during 1-year observation.

Use of drotrecogin alpha (recombinant human activated protein C, rhAPC) in the treatment of severe sepsis induced by graft pancreatitis after simultaneous pancreas and kidney transplantation: a case report.

We present our experience with recombinant human activated protein C (rhAPC) to treat a 40-year-old preemptive simultaneous pancreas-kidney transplant (spktx) recipient who developed septic shock due to graft pancreatitis. We diagnosed intra-abdominal septic complications with septicemia induced by multiple pathogens and cardiopulmonary insufficiency. Until the 59th posttransplant day, 21 peritoneal lavages were performed to treat peritonitis and intra-abdominal abscesses. On the 53rd day when septic shock was diagnosed, rhAPC was administered, after which the patient improved, vasoconstrictive agents were reduced, and respiratory insufficiency resolved. The Physiologic and Operative Severity Score for enumeration of Mortality and Morbidity (POSSUM) scale showed a decrease in predicted mortality from 93% to 17% on day 7 after rhAPC initiation. The patient was discharged at 128 days after spktx with good function of both grafts. Administration of rhAPC limited systemic inflammatory response syndrome (SIRS) and may be considered when faced with the dilemma of stopping immunosuppression to save a recipient's life but at the cost of rejection of a functioning graft.

Influence of pancreas and kidney transplant function on recipient survival.

The aim of this study was to evaluate long-term survival after simultaneous pancreas and kidney (SPK) transplantation in relation to function of both grafts. Among 67 recipients who received SPK transplants between 1988 and 2004, 35 had follow-up longer than 18 months, and were divided into: group I (n = 20), recipients with good function of both grafts; group II (n = 7), patients who had lost transplanted pancreas but had still good kidney graft function; group III (n = 8), patients who had lost both grafts. Comparison of survival rates and analysis of the reason of mortality among groups was performed. The cumulative survival rate was significantly higher in group I than in group III (after 3, 5, 10 years: 100%, 100%, 80% vs 75%, 50%, 37%, respectively). Cumulative survival rate for group II after 3, 5, 10 years was 100%, 100%, 33%, respectively. There were no significant differences in survival rates between groups I and II and between groups II and III. In group I deaths for cardiovascular event and for leukemia were noted. In group II deaths due to cardiovascular event and sepsis were observed. In group III all patients died due to cardiovascular events and the mean time from loss of pancreas and kidney graft function to death was: 75 +/- 51 months (range from 19 to 142), and 49 +/- 26 months (range 19 to 99), respectively. Good pancreas and kidney graft functions prevent death due to cardiovascular event.

A solution to organ shortage: vascular reconstructions for pancreas transplantation.

Multiorgan harvesting (MOH) accounts for approximately 40% of all organ procurements in Poland. Simultaneous procurement of the pancreas and liver necessitates division of the vessels supplying both organs. Therefore, reconstruction of the pancreas vasculature is mandatory for proper function of the transplanted organ. The aim of this study was to present various methods of vascular reconstruction to prepare the pancreas for transplantation. Between January 1999 and April 2005, among 42 whole pancreas transplantations, 35 came from MOH necessitating arterial reconstruction. In 32 cases, the splenic artery (SA) and superior mesenteric artery (SMA) were sewn into a single trunk using the common iliac arterial bifurcation. Occasionally, the iliac Y-graft was unsuitable for vascular reconstruction due to atherosclerosis or iatrogenic injury. Therefore, the SA was anastomosed to the side of the SMA in two cases. In one case we utilized the brachiocephalic trunk bifurcation. Portal vein elongation employed an external iliac vein procured from the donor in all 35 cases. Good perfusion was achieved in all transplanted pancreata. During the early follow-up period, two venous and one arterial thromboses were noted. No negative effects of pancreatic vessel reconstruction were observed in postoperative graft function. Reconstruction of the pancreas vasculature did not affect the long-term function of the allograft while significantly increasing the available donor organ pool.

Comparison of 1-year patient and graft survival rates between preemptive and dialysed simultaneous pancreas and kidney transplant recipients.

It is well known that the main decrease in graft and recipient survival rates is observed during the first 12 months after transplantation. Improving results during this period seems to be crucial for the late outcome. The aim of this study was to compare 1-year survival rates of dialyzed and preemptive pancreas and renal graft recipients and their graft function. From November 1999 to January 2005, 42 whole simultaneous pancreas and kidney transplantations (spktx) were stratified into group I (n = 13): recipients who received a preemptive pancreas and kidney transplant versus group II (n = 29): previously dialyzed spktx recipients. The mean time of dialysis for group II was 39 +/- 16.5 months. We assessed 1-year cumulative survival rates for recipients and grafts for each group. The 1-year cumulative survival rate for preemptive graft recipients was significantly higher than that for dialyzed patients before spktx (100% vs 69%; P = .05). For groups I and II 1-year cumulative graft survival rates for kidney grafts were 100% and 89%, respectively, and for pancreatic grafts 84% and 65.5%, respectively. There was a significant improvement in the 1-year survival rate of preemptive spktx recipients compared with patients dialyzed before spktx. However, 1-year pancreas and kidney graft function did not differ significantly between the groups.

Proinsulinemia in simultaneous pancreas and kidney transplant recipients.

It has been shown that lipid profiles do not differ between pancreas recipients with systemic and portal venous anastomosis. However, it is unclear whether venous drainage from the transplanted pancreas has an impact on recipient atherogenesis and if other factors should be considered. Increased concentration of proinsulin correlates with tachycardia and other risk factors for ischemic heart disease. The aim of this study was to compare proinsulin levels in different types of pancreatic graft venous drainage. Twenty-four simultaneous pancreas and kidney transplantation (SPK) recipients with systemic venous drainage (group S, n = 12) and portal venous drainage (group P, n = 12) under identical immunosuppressive treatment were prospectively observed during 24 months. Following transplantation, only recipients with normoglycemia, normal HbA1c, and normal serum creatine were evaluated. Proinsulin was assessed in fasting state; after glucagon stimulation (Delta-proinsulin), and during oral 75-g glucose tolerance test twice: between 3 and 6 months and 12 to 24 months posttransplantation. All SPK patients had higher proinsulin concentration in fasting state compared with age-matched healthy controls. After stimulation, proinsulin level did not significantly differ between groups; the type of the pancreas venous anastomosis did not change the release of proinsulin and should not have impact on cardiovascular risk factors.

Duodenal patch and sphincterotomy: modification of an old technique to prevent graft pancreatitis.

The aim of this study was to preliminarily evaluate the duodenal patch technique combined with open sphincterotomy in terms of prevention of graft pancreatitis. From April 2003 to March 2005, 17 simultaneous pancreas and kidney transplantations were performed using this technique. All recipients are alive with good renal transplant function. Directly after sphincterotomy in 16 pancreatic grafts a good outflow of clear pancreatic juice and a lessening of graft tenseness were observed during surgery. In two transplants an additional sphincterotomy of the Santorini duct sphincter was necessary. In one recipient no pancreatic juice secretion was observed and insulin independence was not obtained. This graft was explanted shortly afterward. In 13 recipients no graft pancreatic or peripancreatic fluid collection requiring intervention was observed. Of the three recipients who developed graft pancreatitis, two required graft pancreatectomy. In conclusion, Sphincterotomy facilitates pancreatic juice outflow by reducing intraoperative graft edema, which could lead to subsequent inflammation. Further studies on the factors inducing graft pancreatitis are necessary to eliminate this severe complication.

Usefulness of Modified Dindo-Clavien Scale to Evaluate the Correlation Between the Severity of Surgical Complications and Complications Related to the Renal and Pancreatic Grafts After Simultaneous Kidney and Pancreas Transplantation.

OBJECTIVE: Simultaneous pancreas and kidney transplantation (spktx) is the multiorgan transplantation. Thus various complications originated from transplanted organs and the complications that are not directly related to pancreatic or renal grafts could be developed at the same recipient. AIM: The aim of this study is to explore whether there is a correlation between the severity of complications originated from transplanted pancreas, transplanted kidney and general surgical complication developed at the same spktx recipient. METHODS: Complications which developed among 112 spktx recipients were divided into three groups: related to the pancreatic graft (PTXc), to the renal graft (KTXc) and the general surgical complication (GNc). Severity of postoperative complications using modified Dindo-Clavien scale recipients was evaluated for each group. The correlation of severity of coexisting complications from different complication groups was analyzed. RESULTS: There were 22 recipients who developed the coexistence of complication between different complication groups. Complication originated from two and three complication groups developed 15 (68.2%) and 7 (31.8%) patients, respectively. There was not found correlation of the complication severity between: KTXc and GNc group, GNc and PTXc group, KTXc and PTXc group. The correlation (r = 0.84) of complication severity in recipients who developed concurrently complication from transplanted kidney, transplanted pancreas and general surgery complication was found. CONCLUSION: The modified Dindo-Clavien scale is an useful methodology for the correlation description of complication severity in complex multiorgan transplantation such is spktx, especially when the complications originated from different, potentially independent from the pathophysiological point of view, sources.

Surgical Complications Not Related to the Renal and Pancreatic Grafts After Simultaneous Kidney and Pancreas Transplantation.

BACKGROUND: Simultaneous pancreas and kidney transplantation (SPKTx) is the most commonly performed multiorgan transplantation procedure worldwide. Transplanted organs are the main source of complication; however, some postoperative complications are not directly related to the pancreatic or renal grafts. The goal of this study was to evaluate the prevalence, type, and severity of postoperative complications not related to transplanted kidney or pancreas among SPKTx recipients. METHODS: Complications unrelated to transplanted pancreas and kidneys among 112 SPKTx recipients were analyzed. The cumulative freedom from general surgical complications was assessed, and it was compared with cumulative freedom from complications related to kidney and pancreatic grafts. Severity of complications was classified according to a modified Clavien-Dindo scale. RESULTS: The general surgery complication rate was 22.2%. Cumulative freedom from general surgical complications at days 60 and 90 after transplantation was 0.89 and 0.87, respectively. Cumulative freedom from general surgical complications was comparable with cumulative freedom from complications related to kidney grafts but significantly higher than cumulative freedom from complications related to pancreatic grafts (log-rank test, P < .001). The rates for grades of severity II, IIIa, IIIb, and IVb were 19.4%, 9.7%, 64.5%, and 6.4%, respectively. The most frequent cause of complications was intra-abdominal hematoma or abscess (25.8%). CONCLUSIONS: The general surgical complication rate was comparable to the rate of complications originating from the renal grafts but significantly lower than the complication rate related to the transplanted pancreas. The incidence of general surgical complications could be defined as moderate, and the severity of this type of complication was low.

Polyoma BK virus reactivation in kidney and pancreas-kidney recipients.

BK virus infection has become important factor affecting graft function in renal transplant recipients. One of the most important complication of BK infection is nephropathy in patients after renal transplantation. The aim of this study was to evaluate incidence of BK reactivation and nephropathy in our population of renal allograft recipients. One hundred twelve renal or pancreas-kidney allograft recipients were included for the 24 months follow-up. The incidence of BK nephropathy was 7.85% and viremia 27.96%. In the second study group there were 28 patients with graft function deterioration evaluated at the time of biopsy. In this group incidence of BK nephropathy was 7.1% and viral reactivation was diagnosed in 10.7% of patients. In our center, the incidence of BK nephropathy is the same as worldwide. The risk of BK virus replication is highest during first 15 months after the surgical procedure.

Endothelin-1 and neuropeptide Y plasma concentrations in renal venous blood of hypertensive patients with unilateral renal artery stenosis.

The aim of the study was to investigate endothelin-1 (ET-1) and neuropeptide Y (NPY) plasma concentrations in renal venous blood of hypertensive patients with unilateral renal artery stenosis (URAS). The study was performed in 22 patients with URAS and 18 patients diagnosed as essentially hypertensive. In each subject renal arteriography and renal vein catheterisation was performed. Blood samples for ET-1, NPY and plasma renin activity (PRA) were withdrawn from renal veins and vena cava inferior, and for ET-1 and NPY from the aorta. Patients with URAS were divided in two subgroups according to the renal vein renin ratio. Both in nine patients with URAS and ratio > 1.5 and in 13 patients with URAS and ratio < 1.5, ET-1 and NPY plasma concentrations evaluated in renal venous blood of the ischaemic kidney were not different from those assessed in the contralateral side, in vena cava inferior and in the aorta. In essential hypertension, the mean ET-1 and NPY plasma concentrations of both renal veins were not different from the ET-1 and NPY plasma values assessed in renal vein of stenosed and contralateral side, vena cava and aorta of patients with URAS with and without activation of the renin system. Our study indicates that chronic ischaemia does not affect ET-1 and NPY plasma concentrations in renal venous blood of hypertensive URAS patients both with and without activation of the renin system.

Renal transplantation in Warsaw: a registry report.

In a country undergoing socioeconomic transformation, with all the attendant financial difficulties, it is rather difficult to obtain very good results in this expensive and advanced method of therapy. However, in spite of such difficulties, the results obtained are equal to the European standards, with 85% and 65% one- and five-year graft survival, respectively.

Immunosuppression in kidney transplantation in Poland.

This paper presents experience with cyclosporine A in kidney allograft recipients at the Transplantation Institute, the Medical University of Warsaw. Comparative studies on pharmacokinetics and bioavailability of CsA and Neoral as well as monitoring of the drug immunosuppressive activity are presented. The implementation of CsA to immunosuppressive therapy in renal allograft recipients have greatly improved the grafts and patients survival. CsA has been used in a great percentage of patients after renal allograft in Poland (72%) and seems to be in some patients the gold standard of immunosuppression.

36-month follow-up of 75 renal allograft recipients treated with steroids, tacrolimus, and azathioprine or mycophenolate mofetil.

OBJECTIVES: The aim of this retrospective study was to assess the incidence of acute rejection episodes (AR), diabetes mellitus (DM), and serum creatinine (SCr) among renal transplant recipients treated with tacrolimus (Tac), steroids (S), and mycophenolate mofetil (MMF) or azathioprine (Aza). METHODS: Seventy-five renal allograft recipients enrolled in the COSTAMP study were followed for a period of 3 years. Patients were randomized to receive either Tac and MMF (n = 41) or Tac and Aza (n = 34) concomitantly with steroids. Follow-up assessments were performed at 3, 6, 12, 24, and 36 months. RESULTS: Patient survival at month 36 was 91.18% in the Tac/Aza/S group and 97.56% in the Tac/MMF/S group. Graft survival at month 36 was 82.35% and 85.37%, respectively. During the study period, 22 cases of biopsy-proven AR were diagnosed in 17 patients (22.6%). After 36 months the total number of AR was 11 in the Aza-treated group (32.4%) and 11 in the MMF-treated group (26.8%). DM was diagnosed de novo in 17 individuals (22.6%). During 36 months, 10 patients from Aza-treated group (29.4%) and seven from MMF-treated group developed DM (17.1%). Serum creatinine values were not significantly different in both arms of the study. Comparison of arterial blood pressure and total cholesterol revealed no significant changes in any of the studied groups. CONCLUSIONS: We conclude that combinations of steroids, tacrolimus, and azathioprine or MMF provide good results with regard to renal function.